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3) Metered-dose inhalers: a) pressure aerosol with external electronic devices that record the time of actuation15; and b) dry powder that records advancement of next dose or inhalation. Dry powder devices that are activated by inhalation are more indicative of medication use.16 4) Video observation of patient taking medication.
ADHERENCE TRAINING
For clinicians to be successful in helping patients follow a treatment plan they must be able to: 1) accurately diagnose patient adherence; 2) be knowledgeable of methods to improve adherence;
and 3) have the ability to incorporate behavioral skills and adherence programs into their daily practice.17 AAP training addresses these topics simultaneously. Many individual adherence interventions (education, pharmacy programs, counseling, behavioral, reminders)
by themselves have been employed
by investigators with some success. Comprehensive interventions combining cognitive, behavioral, and affective (motivational) components are more effective than single-focus interventions17 (see Table 2). Information alone is not enough for creating or maintaining good adherence. Adequate evidence exists to health care system teams rather than traditional, independent physician practice and minimally structured systems.
First-line interventions to optimize adherence must go beyond the
provision of advice and prescriptions.
It is important that clinicians identify patients who do not value the health or may not “be ready” to change their behavior. Prochaska & DiClemente have
as pre-contemplation, contemplation, preparation, action, and maintenance.18 adults with asthma who may not be ready to adopt a preventive medication plan.19
AAP OVERCOMES BARRIERS TO ADHERENCE WITH TARGETED STRATEGIES
Patients have reasons why they find
it difficult to follow treatment plans. These are referred to as barriers
of adherence. Global Initiative for Asthma (GINA) 2008 has listed
them as both Drug and Non-Drug.20 Drug-related factors include cost,
side effects, complex regimens, and dislike of medication. Non-drug related factors include misunderstanding or lack of instruction, dissatisfaction
with health care, underestimation of severity, unexpressed fears or concerns, and forgetfulness or complacency. Identification of these barriers initiates the adherence management process. The have been incorporated within the Asthma Adherence Pathway.TM Strategies for
each barrier have been developed and proven in research projects listed in the timeline side bar. Without knowledge
of a patient’s barrier, the practitioner does not have the basic understanding to develop an effective strategy.10
COMMUNICATION SKILLS
Motivational Interviewing19 and
Shared Decision Making21 are communication skills that have been utilized in asthma adherence programs. how important it is to the patient to follow asthma management plans and
First-line interventions to optimize adherence must go beyond the provision of advice and prescriptions.
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By understanding the patient’s stage
of readiness in accepting medication and management recommendations,
the clinician can begin to motivate
the patient to consider an effective treatment plan. Motivational Interviewing works best when patients are ambivalent about following health recommendations. Shared treatment decision-making is patient-centered
care that enables patients to participate in management of their own health.21
In Shared Decision Making the patient provides information to the physician on values and preferences and the physician gives treatment options, including
AAP offers clinicians training in both communication skills.
POTENTIAL INTEGRATION OF ADHERENCE MANAGEMENT PROGRAMS WITHIN THE HEALTH CARE SYSTEM
Pharmaceutical companies recognize the relationship between adherence
and product sales and have invested
in adherence monitoring technology. While monitoring is one component
of adherence management, programs like the Asthma Adherence PathwayTM will guide physicians on the methods to change patient behavior. Medicare has recently changed reimbursement from
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Del Med J | July 2017 | Vol. 89 | No. 7
