Improving inhaler technique and adherence: a complex problem in practice Sinthia Bosnic-Anticevich, PhD Principal Research Fellow Sydney Medical School, University of Sydney Research Leader and Director of Development Woolcock Institute of Medical Research

Inhaler technique and adherence The when and how of medication management…

symptoms history pattern of symptoms spirometry ? alternative diagnosis bronchoprovocation allergy tests exhaled NO severe asthma/ uncontrolled asthma Empiric treatment ICS + prn SABA severe asthma/ uncontrolled asthma Review/adjustment Assessadjustreview response

Implementing HARP (Helping Asthma in Real Patients): Improving asthma control through assessment and inhaler education David Price, et al.

77% poorly controlled 90% ‘non-adherent’ 72–83% demonstrated device handing errors

Inhaler technique 78% not well controlled All patients (n=200) performed at least 2 errors. 72% of patients performed at least 5 errors

GINA and medication management principles? Control-based management Long term goal Achieve good symptoms control Minimize future risk of exacerbations, fixed airflow limitation and side effects Evidence based treatment options Patients goals should be identified  a partnership Communication skills of HCPs  patient satisfaction, better health outcomes Patient characteristics and phenotypes, patient preferences and practical issues (inhaler technique, adherence and cost to the patient) but…..

In practice……. Patients have flare-ups Severe asthma vs uncontrolled asthma ? Inhaler technique Medication adherence Incorrect diagnosis Co-morbiditites and complicated conditions Ongoing exposure to triggers Knowing what patients should be doing required careful investigation. Getting them to do it is difficult. Why? Incorrect diagnosis – upper airway dysfunction, cardiac failure, lack of fitness. Comorbiditites – complicate conditions such as rhinosinusitis, gastroeosophageal reflyx, obesity, OSA

Drilling down to the ‘practical issues’……. Adherence

Compliance Adherence Concordance The extent to which a patient’s behaviour matches the prescriber’s advice Adherence The extent to which the patient’s behaviour matches agreed recommendations from the prescriber Concordance A complex idea relating to the patient/prescriber relationship and the degree to which the prescription represents shared decision.

Adherence Up to 70% of adults with asthma do not take their medication as prescribed. Why? Do not want to? Are not able to? Can not remember to? It is complex and we need to understand more

There is no ‘typical’ non-adherer

Adherence NEED CONCERNS Illness Perceptions Background Beliefs Self-management NEED Perceived CONCERNS Side effects Attribution of side effects Illness Perceptions Symptom experiences, expectations and interpretations Background Beliefs Negative orientation to medicine in general Beliefs about personal sensitivity Past experiences Practical difficulties Views of others Self efficacy Cultural influences Satisfaction Contextual issues

7 factors associated with poor adherence: Perceived necessity, safety concerns, acceptance of chronicity and medication effectiveness, advice from family and friends, motivation and routing, ease of use, satisfaction with asthma management.

Interventions to improve adherence Cochrane review 2008. Randomised Controlled Trials. Adherence Clinical outcomes Minimum of 6 months 78 trials. 93 interventions.

Example of interventions Increased information Appointment and prescription refill reminders Counselling on specific disease, treatment etc Different medication formulations Automated telephone , CA patient monitoring and counselling Crisis intervention conducted when necessary Manual telephone follow-up Lay health mentoring Family intervention Augmented pharmacy services Various ways of increasing convenience of care Psychological therapy (CBT) Mailed communications Simplifying dosing Group meetings Involving patients more in care through home monitoring Reminders e.g. programmed reminders Special reminder pill sets Dosing dispensing charts

Example of interventions Increased information Appointment and prescription refill reminders Counselling on specific disease, treatment etc Different medication formulations Automated telephone , CA patient monitoring and counselling Crisis intervention conducted when necessary Manual telephone follow-up Lay health mentoring Family intervention Augmented pharmacy services Various ways of increasing convenience of care Psychological therapy (CBT) Mailed communications Simplifying dosing Group meetings Involving patients more in care through home monitoring Reminders e.g. programmed reminders Special reminder pill sets Dosing dispensing charts

What works? 1/3 were associated with improved adherence Reminders Complex and in combination Information Self-monitoring Reinforcement Counseling Family therapy Psychology therapy Manual telephone follow up Supportive care

Drilling down to the other ‘practical issue’……. Inhaler Technique

The considerations Up to 90% of people make handling errors. Across all devices Some errors are more likely to be related to poor asthma control Some devices are more intuitive to use Once you have learnt how to use one, the next one is easier Should be straightforward…….

Can we improve inhaler technique? Yes, with the right type of education ✓ ✗

Can we improve inhaler technique? Yes, with the right type of education If education is repeated over time

Can we improve inhaler technique? Yes, with the right type of education If education is repeated over time TH group ACC group 3 2 1 20% 40% 60% 80% 100% 0% 6 Months 100% 6 80% 3 2 1 60% 40% 20% 0% 1 2 3 Months

Can we improve inhaler technique? Yes, with the right type of education If education is repeated over time TH group 100% 6 80% 3 2 1 60% 40% 20% 0% 1 2 3 Months

Can we improve inhaler technique? Yes, with the right type of education If education is repeated over time It can be done in a timely manner (TH) (ACC) 7 7 6 6 5 5 Time of inhaler technique education mean (95% CI) 4 4 3 3 2 2 1 1 1 2 3 6 1 2 3 6

But, it is not so simple… 73% perceive their inhaler technique to be good or excellent 86% find their inhalers easy to use 95% have not had their inhaler technique checked in the last 12 months!!

WHY do patients not use their inhalers correctly, even when they are taught how?

The Inhaler Technique Maintenance Framework 1. Perceived threat of asthma 2. Self-management beliefs 3. Self-management self-efficacy

The Inhaler Technique Maintenance Framework Symptom experience Witnessing asthma in others Comorbidities Value of health and asthma control Emotions, e.g. fear versus complacency Family impact NECESSITY 1. Perceived threat of asthma 2. Self-management beliefs 3. Self-management self-efficacy

The Inhaler Technique Maintenance Framework Overarching attitude to medication Preventer necessity beliefs perceived threat asthma perceived benefits preventer knowledge of preventer role Preventer concerns Side effects experienced CONCERNS 1. Perceived threat of asthma 2. Self-management beliefs 3. Self-management self-efficacy

The Inhaler Technique Maintenance Framework 1. Perceived threat of asthma General life stresses (e.g. financial struggle) Support from significant others Practical and emotional Emotions, e.g. despair and hopelessness versus caution and optimism 2. Self-management beliefs 3. Self-management self-efficacy

The Inhaler Technique Maintenance Framework A new paradigm Is a complex process More than just a physical skill Intrinsically linked with other aspects of asthma management Fixing the problem will not be so easy…

Should we be looking at them together? Adherence and inhaler technique The co-exist Preliminary research IT maintenance = adherence + baseline technique + device type (n=233) We have ways to measure this INCA (INhaler Compliance Assessment) The common patient factors Necessity Concerns Motivation Overall management of asthma

Further considerations Are some devices favoured/more intuitive, and more likely to be used properly? Are there special populations that we should be considering? Intellectual disability Elderly/cognitive impairment/ physical impairment disadvantaged When do the problems start? Childhood/medication taking autonomy How can we help each other?

Solutions HCP working together. Understanding the patient perspective. Considering special populations……

HCP working together

Collaboration in Asthma Management in the Community CAMCOM Model 1 Training together. GPs, practice nurses, Pharmacists. Model 3 Collaborative, IPL Sociocultural theory of learning Model 2 Web-based Background Education on inhaler devices “Hands-on” training Protocol presentation Individual 1. Interaction 2. 3. Internalisation 4. Transformation 5. Long Term Change E-patient record

Understanding the patient’s networks and their influence

Understanding the patient’s networks and their influence

Individuals with Intellectual Disability

Impact and implications It has to be based on the best science, but it needs to be relevant to the patient. One size does not fit all. New Asthma Management Guidelines/reports Training of undergraduate Medical, Pharmacy and Nursing students Continuing Professional Education courses We need to work together Resources. Novel inhalers and support material for HCP and patients. We need to make a discussion about the use of inhalers exciting….

Impact and implications It has to be based on the bets science, but it needs to be relevant to the patient. One size does not fit all. New Asthma Management Guidelines/reports. Training of undergraduate Medical, Pharmacy and Nursing students. Continuing Professional Education courses. Resources. Novel inhalers and support material for HCP and patients. We need to make a discussion about the use of inhalers exciting….