Bruce G. Bender

Noncompliance and treatment failure in children with asthma.

BACKGROUND Accurate and reliable information about childrens use of inhaled medications is needed because of the growing reliance on these drugs in the treatment of asthma and the excessive morbidity and mortality attributable to this disease. OBJECTIVE This study was designed to evaluate the adherence of children with asthma to regimens of inhaled corticosteroids and beta-agonists. METHODS Data collected electronically by metered-dose inhaler monitors were compared with data recorded by patients on traditional diary cards. A volunteer sample of 24 children, between 8 and 12 years old, who had asthma for which they were receiving both inhaled corticosteroids and beta-agonists, participated over a 13-week period. Each child was accompanied by a parent to all study visits. The main outcome measures were the use of medication as reported by diary card entries and recorded by electronic monitoring and disease exacerbation, as indicated by requirement for oral corticosteroids. RESULTS The median use of inhaled corticosteroids reported by patients on their diaries was 95.4%, whereas the median actual use was 58.4%. More than 90% of patients exaggerated their use of inhaled steroids, and diary entries of even the least compliant subjects reflected a high level of adherence. The children who experienced exacerbation of disease sufficient to require a burst of oral corticosteroids differed markedly from the others in their adherence to prescribed therapy as recorded by the electronic monitors. The median compliance with inhaled corticosteroids was 13.7% for those who experienced exacerbations and 68.2% for those who did not. CONCLUSIONS Electronic monitoring demonstrated much lower adherence to prescribed therapy than was reported by patients on diary cards. Low rates of compliance with prescribed inhaled corticosteroids were associated with exacerbation of disease. Poor control of asthma should alert the physician to the possibility of noncompliance.

Nonadherence in Asthmatic Patients: Is there a Solution to the Problem ?

LEARNING OBJECTIVES Reading this article will reinforce the readers awareness of the relationship between adherence and treatment outcome, of the causes of nonadherence, of methods of measurement, and of steps toward successful intervention. DATA SOURCES Articles on adherence to asthma therapy were reviewed. A MEDLINE database using subject keywords was searched from 1990 through 1997. STUDY SELECTION Pertinent articles were chosen, with preferential presentation of results from controlled studies. RESULTS There is no evidence of recent improvement in the rates of nonadherence, and patients continue on average to take about 50% of prescribed medication. Nonadherence assessment is most accurate when it can be measured objectively, and relies neither on patient report nor physician estimate. The consequences of nonadherence are measured in patient suffering, financial cost, and serious compromise of clinical trial outcomes. Underlying causes of nonadherence are traced to characteristics of the disease, treatment, patient, and caregiver system. CONCLUSION Improved adherence will lead to improved disease control, but only if medical care systems encourage and support the allocation of sufficient resources to allow barriers to self-management to be discussed and solutions negotiated. Attempts to improve adherence outside of the caregiver-patient relationship are less likely to succeed. Special programs for difficult-to-manage patients are necessary to change behavior, although significant illness improvement and cost savings are likely to result.

Adherence intervention research: What have we learned and what do we do next?

Although there is general agreement from studies demonstrating that adherence to inhaled corticosteroid therapy is often inadequate to establish consistent control, relatively little concurrence exists in reports of interventions to correct the problem. Half of the studies reviewed found that the experimental intervention did not change adherence, and behavior change reported by patients was often not accompanied by changes in treatment success. Studies used a variety of methods that differed in quality with findings that were often contradictory. Key limitations in many studies included reliance on inadequate adherence measures, inclusion of convenience samples of well-motivated patients, and assessments of intervention outcomes artificially boosted by attrition of least adherent participants. Research is encouraged into innovative interventions that are brief, easily implemented, and can be tailored to individual patients and diverse clinical settings. Of particular importance is inclusion of hard-to-reach patients, including urban and rural poor and the use of valid measures of adherence at intervals sufficient to establish enduring benefit.

Brain morphology in Klinefelter syndrome: extra X chromosome and testosterone supplementation.

Objective: This study focuses on variation in brain morphology associated with supernumerary X chromosome and Klinefelter syndrome (KS). Using an unselected birth cohort of KS subjects and high-resolution MRI, the authors investigated the neuroanatomic consequences of the 47,XXY karyotype in the presence and absence of exogenous testosterone supplementation. Methods: Regional brain volumes were measured in 10 subjects with KS and 10 age-matched control men. Five of the KS subjects had received testosterone supplementation since puberty (KS+T) and five had not (KS−T). Results: KS subjects showed significant (p < 0.01) reduction in left temporal lobe gray matter volumes compared with normal control subjects. Differences in left temporal gray volumes were also significant between the KS+T and KS−T groups (p < 0.01). Verbal fluency scores were significantly different between the KS+T and KS−T groups as well. Conclusion: Supernumerary X chromosome material in men is associated with a reduction in left temporal lobe gray matter, a finding that is consistent with the verbal and language deficits associated with KS. Also, relative preservation of gray matter in the left temporal region is associated with exposure to exogenous androgen during development. A history of testosterone supplementation also appears to be associated with increased verbal fluency scores in KS patients.

Medication non-adherence and asthma treatment cost.

Purpose of reviewThe purpose of this review is to describe the impact of asthma treatment non-adherence on patients and the healthcare system, and to outline areas of responsibility towards improved adherence. Recent findingsThe average cost of healthcare expenses for each person in the United States in 2002 was US

Pituitary-gonadal function in Klinefelter syndrome before and during puberty.

5440. In that year, there were 800 million medical encounters. However, adherence research suggests that a significant portion of the healthcare advice and prescriptions dispensed in these encounters was wasted. The annual cost to the healthcare system caused by non-adherence has been estimated at US

Negative affect, medication adherence, and asthma control in children.

300 billion dollars. The responsibility for improving adherence has usually been placed on the patient and healthcare provider. However, if non-adherence is to be more effectively addressed, other components of the healthcare and pharmaceutical industries must also take responsibility. SummaryTreatment non-adherence compromises treatment effectiveness and drives up the healthcare costs related to asthma and other chronic conditions. Collaborative efforts to improve adherence to treatments for chronic illness, recently promoted by the World Health Organization, must include multiple components of the healthcare system, must recognize that the costs of adherence promotion are outweighed by cost savings after improved adherence, and must support research to develop new and better strategies for improving adherence.

Impact of Interview Mode on Accuracy of Child and Parent Report of Adherence With Asthma-Controller Medication

ABSTRACT: Serum concentrations of follicle-stimulating hormone, luteinizing hormone, testosterone, and estradiol were determined at intervals before and during puberty in 40 individuals with Klinefelter syndrome (47,XXY karyotype), of whom 27 had been detected in neonatal cytogenetic screening programs. Prior to the appearance of secondary sexual changes, basal serum hormone concentrations and acute responses to stimulation with gonadotropinreleasing hormone and human chorionic gonadotropin were normal. The timing of the onset of clinical puberty was normal. Early pubertal boys showed initial testicular growth and normal serum testosterone levels, while serum follicle-stimulating hormone and estradiol concentrations were significantly elevated. By midpuberty, the Klinefelter subjects were uniformly hypergonadotropic and their testicular growth had ceased. Serum testosterone concentrations after age 15 remained in the low-normal adult range. Serum estradiol levels remained high, irrespective of the presence or absence of gynecomastia. Exaggerated responses to gonadotropin-releasing hormone are seen in pubertal subjects with elevated basal gonadotropin values.

Effects of X-Monosomy and X-Linked Imprinting on Superior Temporal Gyrus Morphology in Turner Syndrome

BACKGROUND Negative affect including depression is known to be associated with asthma control, but whether and how it influences control in children with asthma is not understood. OBJECTIVE The objective of this investigation was to evaluate whether negative affect and medication nonadherence each predict decreased symptom control, and whether the relationship between negative affect and disease control is explained by childrens adherence to asthma medications. METHODS Participants included 104 children 8 to 18 years old being treated with an inhaled corticosteroid delivered by metered-dose inhaler for asthma diagnosed by their health care providers. Children and parents independently rated asthma symptoms and completed questionnaires assessing sad and anxious affect. Electronic devices were attached to each participants metered-dose inhaler to measure adherence. At study completion, records were collected to confirm reports of health events. RESULTS Both child and parent negative affect scores predicted symptom scores, whether reported by child or parent, and child negative affect scores predicted school absence because of asthma. In a lagged analysis taking into account time sequence, medication adherence predicted prednisone bursts but not subjective symptom scores. Nonadherence did not explain the relationship between negative affect and symptom scores, but parent negative affect predicted prednisone bursts even when controlling for level of adherence. CONCLUSION Although both negative affect and adherence were predictive of asthma control, the relationship of each to asthma control was distinctly different. Accuracy of symptom perception may be influenced by patient and parent affect characteristics.

Adherence to inhaled corticosteroids: An ancillary study of the Childhood Asthma Management Program clinical trial

OBJECTIVES. Parents and children often overreport adherence to treatment regimens, which in turn complicates interpretation and application of clinical trial findings. The objective of this investigation was to test the effect of reporting mode on accuracy of inhaled corticosteroid-adherence reporting in children with asthma and their parents under conditions similar to those of an asthma clinical trial. PATIENTS AND METHODS. Participants included 104 children who were being treated with an inhaled corticosteroid delivered by a metered-dose inhaler for asthma diagnosed by their health care provider. Each parent and child dyad was randomly assigned to 1 of 3 self-report adherence-assessment modes: (1) audio computer-assisted self-interviewing; (2) face-to-face interview with study staff; or (3) self-administered paper-and-pencil questionnaire. At the 4 monthly visits, the parent and child were interviewed separately and asked questions about adherence on the previous day and in the past week. Electronic devices were attached to the each participants metered-dose inhaler to provide an objective record of actual daily medication activations. RESULTS. Both children and parents greatly overreported their inhaled corticosteroid adherence when queried about either time frame (1 day or 1 week) in any of the 3 interview modes. One of 3 responses reported full adherence when no medication had been taken. Inconsistent with the study hypothesis, discrepancy between self-report and objectively measured adherence was greatest in the computer-interview condition. In the optimal circumstance where children were interviewed by study staff about their adherence within the previous 24 hours, reported adherence was within the ±25% accuracy range for only half of the participants. Larger discrepancy scores were observed for both parents and children when reporting by computer or questionnaire. CONCLUSIONS. Under the best of conditions in this study, accuracy of self-report was insufficient to provide a stand-alone measure of adherence. Verification of treatment adherence by objective measures remains necessary.