Daily routine boosted asthma med adherence
Two simple recommendations for older patients with asthma – keeping medication in the bathroom and integrating its use into a daily routine – can significantly improve adherence to inhaled corticosteroids.
When patients consistently did either of those, adherence rose threefold, compared with patients who didn’t, Dr. Alex Federman and his associates wrote in the August issue of the Journal of Internal Medicine.
The findings suggest that clinicians might help improve adherence by suggesting that their patients store the medication in their bathroom cabinet, and take it, for example, when they brush their teeth every day.
"Because adherence strategies are modifiable, the findings in this study may provide clinicians and care coaches with straightforward and useful messages to help older patients improve their medication adherence," wrote Dr. Federman of Icahn School of Medicine at Mount Sinai, New York, and his coauthors (J. Intern. Med. 2014 Aug. 5 [doi:10.1007/s11606-014-2940-8]).
The team investigated adherence to inhaled corticosteroids among 358 elderly patients with asthma. They were a mean of 67 years old, with 31% older than 70 years. Most (84%) were women and many were Latino (38%). Black patients comprised 31% of the cohort and the others were non-Hispanic whites.
The majority had a low monthly income ($1,350 or less), and 25% were not fully literate in English. Many had comorbid psychological conditions, including depression (20%) and anxiety (21%).
Low health literacy was common (34%), although most (71%) did understand that they would always have asthma and that it could not be cured (81%). But half believed that they had the disease only when they were symptomatic. In a survey of medication beliefs, most did believe that the steroids were good for them and that their benefits outweighed the risks.
However, only 37% of the cohort reported good medication adherence. This proportion was significantly worse among blacks and Hispanics; those with lower incomes and lower education; those born in Puerto Rico and the Dominican Republic; and those with poor physical health, anxiety, or depression.
The authors identified six medication adherence strategies among the group: keeping the medication in a usual location (44%); integrating it into their daily routine (33%); taking it at a specific time of day (22%); taking it with other medications (13%); using it only when needed; (13%) and using other reminders (12%). Less than 2% reported using written notes as a reminder or having someone else remind them; 4% had no specific strategy.
The most common places to keep medicine were at the bedside (20%) and in the bathroom (9%). Those who integrated taking it with other daily routines did in the morning (12%) and at bedtime (8%).
Only three of the strategies were significantly associated with good adherence: keeping medication in the bathroom (16% adherent vs. 5% nonadherent); integrating it into a daily routine (morning 25% vs. 5%; evening 13% vs. 6%); and taking it at a specific time of day (29% vs. 17%).
Taking the medication only when needed was associated with significantly worse adherence.
After controlling for other variables, only leaving the medication in the bathroom significantly predicted good adherence (odds ratio, 3), compared with those who kept it somewhere else).
Those who integrated medication into other daily routines were also significantly more likely to be adherent (OR, 3.7) in a partially adjusted model, but not in a fully adjusted model. Still, the authors noted, this recommendation would be a good suggestion toward improving adherence.
Patients who used these two strategies were more likely to be white, have at least a partial education, and to have been born in the United States. Low income, limited English proficiency, low health literacy, poor physical and psychological health, and erroneous beliefs about asthma predicted poor adherence.
The team postulated that there are two types of nonadherence: simple forgetfulness or lack of understanding about its importance and deliberate nonadherence.
"The bathroom and daily routine strategies may address forgetful nonadherence. ... Taking the medication only as needed, on the other hand, may indicate faulty disease or medication beliefs. ... Taken together, these findings provide further evidence of the value of patient-centered care: Clinicians need to understand why patients do not use their medications appropriately before counseling patients on ways to improve adherence."
The study was supported by a grant from the National Heart, Lung, and Blood Institute. None of the authors had any financial disclosures.
msullivan@frontlinemedcom.com