What predicts poor collection of medication among children with asthma? A casecontrol

Transcription

1 Eur Respir J 2002; 20: DOI: / Prited i UK all rights reserved Copyright #ERS Jourals Ltd 2002 Europea Respiratory Joural ISSN What predicts poor collectio of medicatio amog childre with asthma? A case-cotrol study L. Irvie*, I.K. Crombie*, E.M. Alder #, R.G. Neville }, R.A. Clark z What predicts poor collectio of medicatio amog childre with asthma? A casecotrol study. L. Irvie, I.K. Crombie, E.M. Alder, R.G. Neville, R.A. Clark. #ERS Jourals Ltd ABSTRACT: Compliace with asthma medicatio is recogised to be a problem. Acquisitio of medicatio is the first step towards compliace. Factors predictig poor collectio of prophylactic medicatio were ivestigated. A case/cotrol study was coducted. Cases were childre who had had at least two cosultatios for poorly cotrolled asthma i 1 yr ad collected prescriptios of prophylactic medicatio irregularly. Cotrols were childre whose prescriptios were collected as istructed. Levels of kowledge about asthma ad asthma medicatio were high i both groups. Parets of cases were more likely to perceive their child9s asthma to be moderate or severe ad more likely to report that their child9s asthma was ot well cotrolled. They reported more ight-time symptoms, exercise symptoms ad school absece. Parets of cases were less likely to report that admiisterig ihalers was part of the eveig routie. They were less likely to perceive their child9s prophylactic medicatio to be very effective ad more reluctat to admiister prophylactic medicatio. Some parets may decide to udertreat their childre, although lack of orgaised routie may cotribute to poor compliace. Parets eed guidace o iterpretig symptoms ad support i establishig routies for the admiistratio of medicatio. Eur Respir J 2002; 20: *Dept of Epidemiology & Public Health, Uiversity of Dudee, Niewells Hospital & Medical School, Dudee, # Faculty of Health & Life Scieces, Napier Uiversity, Ediburgh, } Westgate Health Cetre, Dudee, ad z Dept of Medicie, Uiversity of Dudee, Niewells Hospital & Medical School, Dudee, UK. Correspodece: L. Irvie, Dept of Epidemiology & Public Health, Niewells Hospital & Medical School, Dudee, DD1 9SY, UK. Fax: m.a.j.irvie@dudee.ac.uk Keywords: Asthma, case/cotrol study, compliace, prophylactic medicatio Received: December Accepted after revisio: Jue This study was supported by a grat from the Scottish Executive Chief Scietist Office, Ediburgh, UK (Grat umber K/OPR/2/2/D316). May childre with asthma suffer cosiderable morbidity despite the availability of effective treatmets [1]. Asthma remais a commo reaso for admissio to hospital [2] ad cosultatios with the geeral practitioer (GP) [3]. Oe explaatio for this is that asthma sufferers do ot take medicatio as prescribed [4, 5]. Adherece to prescribed regimes of ihaled corticosteroids have bee show to decrease the risk of hospitalisatio [6] ad death due to asthma [7]. May GP practices have established asthma cliics ad a great deal of effort has bee ivested i the educatio of patiets regardig the maagemet of asthma [8, 9]. Asthma medicatios are available i a variety of delivery systems, thus esurig that ihaled medicatio is available to all patiets [10]. Despite this improved kowledge, awareess of the disease ad availability of effective treatmets, compliace with medicatio has ot improved [11, 12]. Paretal ad childhood factors which ifluece compliace with medicatio were ivestigated. The preset study was desiged to ivestigate poor compliace with medicatio that was associated with poor cotrol of asthma symptoms. Acquisitio of medicatio is the first step towards compliace with prescribed medicatio. Iappropriate collectio of prescribed medicatio that was associated with exacerbatios of asthma was therefore used to assess compliace. Materials ad methods The study was approved by the Fife Medical Research Ethics Committee. Twety-ie geeral practices i Fife, Scotlad, provided lists of patiets betwee the ages of 2 12 yrs o prophylactic medicatio for asthma. Data were extracted from the GP asthma registers, repeat-prescribig systems ad patiet case records. Details of the drugs prescribed, dose ad frequecy of admiistratio, ihaler devices ad dates of issue of prescriptios were recorded. I additio, a summary of every cotact for asthma over a period of 1 yr was recorded. Study subjects Cases were childre who had had at least two patiet-iitiated cotacts with the GP for poorly cotrolled asthma over a 1-yr period ad had ot collected prescriptios for medicatio i accordace with the GP9s istructios. The expected frequecy

2 PREDICTORS OF POOR COMPLIANCE IN ASTHMATIC CHILDREN 1465 of collectio was derived from the total amout prescribed ad the daily dose [4, 5]. Cotrols were childre who collected eough prescriptios for asthma medicatio i the 1-yr period to esure that they could adhere to the GP9s istructios; they were matched to the cases by GP practice, age (withi 2 yrs) ad sex. These etry criteria were used to esure the recruitmet of two groups, oe with childre who defiitely did ot use eough medicatio to cotrol their asthma ad the secod with childre who appeared to have complied with therapy. The case records of 1,266 childre (60% male) aged 2 11 yrs were reviewed. Of these, 431 childre fitted the criteria for cases or cotrols. A further 212 childre did ot collect prescriptios i accordace with the GP9s istructios but had had less tha two exacerbatios recorded i their case records ad were therefore excluded. For 623 of the childre, it could ot be determied whether they were complyig with the iteded therapy. The details are to be published elsewhere, but, briefly, the mai reasos were that may were ot o cotiuous medicatio (433) ad, for others, there was iadequate iformatio to assess compliace (324). These umbers do ot add up to 623 sice some childre could be assiged as ocompliat for more tha oe reaso. Of the 431 childre assiged as cases ad cotrols, 264 could be orgaised ito matched pairs (i.e. 132 pairs). The remaiig 167 childre were excluded because o match could be idetified withi the practice. Of the 132 matched pairs, 21 were excluded because iterview data could ot be obtaied o oe member of the pair, resultig i 111 of the 132 pairs beig available for aalysis. The childre were aged yrs (mea 8.0 yrs) (oe child wasw12 yrs due to postpoemet of iterview) ad 138 (62%) were male, reflectig the sex differece i childhood asthma [13]. The paret who was the mai carer of the child was ivited to take part i the study. Families were visited at home ad the participatig paret give a semistructured iterview i order to ascertai kowledge ad beliefs about asthma ad its maagemet as well as providig iformatio o the maagemet of the child9s asthma. The iterviewer was blid to case/cotrol status. Levels of kowledge were assessed from parets9 resposes to statemets about asthma ad asthma medicatios based o a validated questioaire [14]. Statistical methods Factors which predicted compliace were assessed through coditioal logistic regressio aalysis, i which the case/cotrol status (coded 1 or 0) was the depedet variable. The aalysis took accout of the matchig of cases ad cotrols. Demography Results The groups were similar i terms of sociodemographic characteristics. Almost all of the respodets were mothers (91% of cases, 92% of cotrols) ad the majority were married (78% of cases, 84% of cotrols). Slightly more parets of those i the cotrol group had a professioal qualificatio (24% of cases, 28% of cotrols). I both groups, oe-third of parets were i maual occupatios. More of the idex parets i the cotrol group were i full-time employmet (27% compared with 20% of cases) ad more of the cotrol group lived i ower-occupied accommodatio (62% compared with 54% of cases). Noe of these differeces reached sigificace. The childres9 asthma The poor compliers (cases) were sigificatly more likely tha the cotrols to be prescribed high-dose ihaled corticosteroids (23% of cases, 10% of cotrols; odds ratio (OR) 3.00; 95% cofidece iterval (CI) ). Parets of cases were twice as likely to report their child9s asthma as beig moderate or severe (44% of cases, 28% of cotrols; OR 2.13; 95% CI ) ad more tha four times more likely to report cotrol of the asthma as moderate or poor (OR 4.42; 95% CI ). Admiistratio of ihalers There was less-orgaised routie withi the home amog the cases (table 1). Parets of cases were almost twice as likely to report that givig ihalers was ot part of the ormal eveig routie (OR 1.85, 95% CI ). Amog families with two parets, cases were much more likely to have oly oe paret resposible for the supervisio of eveig ihalers. Childre who were poor compliers (cases) were less likely to prompt their parets to admiister the ihaler. Morbidity Parets of the cases reported substatially more morbidity tha those of cotrols, both at the time of iterview ad durig periods whe they cosidered the child9s asthma to be troublesome (table 2). There was a two-fold icrease i the odds of reportig curret ight-time symptoms ad a three-fold icrease i ight-time symptoms whe the child9s asthma was troublesome. There was also a three-fold icrease i the odds of reportig frequet exercise symptoms whe the asthma was troublesome. The chace of school absece i the 6 moths prior to the iterview was almost three times higher for cases. Self-maagemet strategies The majority of parets i both groups reported that the childre atteded a asthma cliic (68% of both groups). Oly oe-half of the childre aged w5 yrs used peak flow meters (51% of cases, 48%

3 1466 L. IRVINE ET AL. Table 1. Admiistratio of ihalers Cases Cotrols Chi-squared df OR for factor level 95% CI Ihalers part of morig routie Yes No Ihalers part of eveig routie Yes No Supervisio of eveig ihalers (two-paret families) Both parets Mother oly Father oly Child prompts parets to admiister prophylactic Always Usually Sometimes Never df: degrees of freedom; OR: odds ratio; CI: cofidece iterval. Table 2. Reported morbidity Cases Cotrols Chi-squared df OR for factor level 95% CI Curret ight-time symptoms No Yes Frequecy of ight-time symptoms whe asthma is troublesome Noe Oce or twice per week Frequetly Frequecy of exercise symptoms whe asthma is troublesome Noe Oce or twice per week Frequetly School absece due to asthma i past 6 moths Noe v1 week w1 week df: degrees of freedom; OR: odds ratio; CI: cofidece iterval. of cotrols), ad just over oe-half of these would icrease their medicatio i respose to a low readig (51% of cases, 57% of cotrols). Few childre used writte self-maagemet plas (14% of cases, 10% of cotrols). The cases were more likely to cosider use of rescue medicatio for a exacerbatio of asthma, although the differece was ot sigificat. More of the cases used ebulised b 2 -agoists (13% compared with 5% of cotrols; OR 3.03; 95% CI ) ad oral corticosteroids (20% compared with 12% of cotrols; OR 2.12; 95% CI ). Efficacy of medicatios The majority of parets i both groups believed that asthma medicatios were effective (table 3). Almost all parets agreed that asthma medicatio could prevet a asthma attack if give regularly ad o time. Further, w84% of both groups believed that it was importat to admiister the prophylactic medicatio eve whe the child was asymptomatic. However, whe parets were asked to assess the efficacy of their child9s curret medicatio, parets of cases were twice as likely to report that their child9s curret prophylactic medicatio was ot very effective (33% of cases, 17% of cotrol; OR 2.29; 95% CI ). Further, more of the parets of cases reported a reluctace to admiister the prophylactic ihaler (15% compared with 6% of cotrols; OR 3.00; 95% CI ). I cotrast, o differece was observed betwee parets of cases ad cotrols i the perceived efficacy of the brochodilator. Parets of cases reported a greater reluctace to use the brochodilator but this differece was ot sigificat. Almost all parets agreed that their child would cotiue to eed medicatio for the ext 3 moths (96% of cases, 95% of cotrols). More of the parets

4 PREDICTORS OF POOR COMPLIANCE IN ASTHMATIC CHILDREN 1467 Table 3. Paretal beliefs about asthma medicatio ad perceived efficacy of curret medicatio Cases Cotrols Chi-squared df OR for factor level 95% CI Asthma medicatio is likely to prevet a attack if give regularly ad o time Disagree Usure Agree It is importat to use the prevetative ihaler eve whe my child does ot have symptoms Disagree Usure Agree Perceived efficacy of the prophylactic Very effective Somewhat effective Perceived efficacy of the brochodilator Very effective Somewhat effective Reluctat to use prophylactic No Yes Reluctat to use brochodilator No Yes My child is likely to have a asthma attack i the ext three moths Disagree Usure Agree Eve whe my child is well I worry about him/her havig a asthma attack Disagree Usure Agree df: degrees of freedom; OR: odds ratio; CI: cofidece iterval. of cases aticipated that their child would suffer from a asthma attack i the ext 3 moths (OR 2.50; 95% CI ). However, there was o differece betwee cases ad cotrols i the proportio of parets who reported worryig about the possibility of a asthma attack whe the child was well (39% of cases, 37% of cotrols). Kowledge Levels of kowledge about asthma ad asthma medicatios were high i both groups. More tha 70% of parets from both groups respoded appropriately to eight of the 12 questios (table 4). Topics where there was ucertaity were the role of atibiotics i Table 4. Proportio of parets givig a appropriate respose to questios i asthma kowledge questioaire True/false Correct respose give % Cases Cotrols Asthma ca be a serious disease T More tha oe i 10 childre will have asthma at some time durig childhood T Childre with asthma have abormally sesitive air passages i their lugs T Wheeze may be due to muscles tighteig i the air passages of the lug T Wheeze may be due to swellig i the air passages i their lugs T Most childre with asthma will have poor growth F Childre with frequet asthma should have prevetative drugs T Ihaled steroids are the most commo treatmet for asthma T Medicatio ca help but caot cure asthma T Ihaled steroids have fewer side effects tha other drugs T Childre ca become addicted to their asthma drugs F Atibiotics are importat i the maagemet of asthma F T: true; F: false.

5 1468 L. IRVINE ET AL. asthma, whether ihaled corticosteroids have fewer side-effects ad whether wheeze may occur due to iflammatio of the airways. Discussio The preset study provides importat isight ito how parets maage asthma i their childre. Regular use of medicatio is more likely whe the admiistratio of ihalers is icorporated ito the daily routie. Compliace is also ehaced if both parets ad the child take resposibility for admiisterig the ihaler. Good compliace may occur because the whole family is more ivolved or the daily routie prompts parets ad childre to use the medicatio [15]. This fidig may provide the mechaism uderlyig a previous report that childre with more cohesive ad orgaised families exhibit better asthma cotrol [16]. Parets of cases were reluctat to use regular ihaled prophylactic medicatio because they were less certai about its efficacy for their child [17]. This is ot simply a aversio to steroids [18], sice these parets were much more likely to use courses of high-dose oral steroids. Parets appear to be more apprehesive about the cotiuous use of medicatio tha they are about short courses of high-dose oral corticosteroids. This supports the fidigs of a recet qualitative study that patiets prefer to maage asthma as a itermittet acute disorder [19]. A fidig of major importace is that the parets of the cases reported substatially more morbidity tha those of the cotrols. This idicates that a failure to use medicatio appropriately is ot simply the result of failure to recogise symptoms [20]. Istead, the parets appear to prefer to treat symptoms as they arise with rescue medicatio. Oe explaatio for the reluctace to use regular prophylactic medicatio could be that may of the parets of cases reported that their childre had periods whe they were asymptomatic (data ot show). If a child remais symptom-free for a period without treatmet, there is a strog icetive to stop takig regular medicatio [21]. Several factors were foud to be uassociated with compliace. Poor compliace has previously bee liked to lower social class, level of educatio ad psychosocial factors [22 24]. However, i the preset study, there was o associatio betwee compliace ad the occupatio or educatioal attaimet of the head of the household or with housig teure. Poor compliace was ot due to lack of kowledge about asthma ad the role of medicatio, as kowledge was high i both groups. Educatio has bee oe of the mai objectives of asthma cliics i recet years [25] ad it is clear that parets are ow give eough iformatio. Iappropriate use of medicatio, however, is ot related to kowledge ad uderstadig of the disease [26, 27]. This may explai the coflict observed betwee kowledge of asthma medicatio ad actios take by parets. A potetial limitatio of the preset study is that, although it is kow that prescriptios for the cotrol childre were collected regularly, it is ot kow that they used their ihalers regularly. However, it would seem ulikely that parets would collect prescriptios so regularly if they did ot ited their child to take the medicatio. I summary, curret educatioal activities provide sufficiet iformatio for parets. However, actios ad itetios regardig treatmet of their child9s asthma are ofte i coflict with their kowledge about the disease ad its maagemet. Several factors appear to ifluece ocompliace, icludig cocers about ihaled corticosteroids, lack of orgaised routie, preferece to treat asthma symptomatically rather tha use prophylaxis, ad acceptace or tolerace of asthma symptoms. Some parets may make a coscious decisio to udertreat their childre, possibly as a meas of miimisig the amout of medicatio admiistered. Parets eed guidace o the iterpretatio of symptoms, discussio as to acceptable levels of medicatio use ad support i the establishmet of routies for treatmet admiistratio to cotrol their child9s asthma. Ackowledgemets. The authors are grateful to the geeral practitioers ad their staff who helped i the idetificatio of families suitable for iclusio i the study. Refereces 1. Powell C, Primhak R. Asthma treatmet, perceived respiratory disability, ad morbidity. Arch Dis Child 1995; 72: Aderso H, Butlad B, Stracha D. Treds i prevalece ad severity of childhood asthma. BMJ 1994; 308: Aderso H. Epidemiology of asthma. Br J Hosp Med 1992; 47: Warer J. Review of prescribed treatmet for childre with asthma i BMJ 1995; 311: Bares P, Josso B, Klim J. The costs of asthma. Eur Respir J 1996; 9: Doahue J, Weiss S, Livigsto J, Goetsch M, Greider D, Platt R. Ihaled corticosteroids ad the risk of hospitalisatio for asthma. JAMA 1997; 277: Suissa S, Erst P, Beayou S, Baltza M, Cai B. Low-dose ihaled corticosteroids ad the prevetio of death from asthma. N Egl J Med 2000; 343: Charlto I, Charlto G, Broomfield J, Campbell M. A evaluatio of a urse-ru asthma cliic i geeral practice usig a attitudes ad morbidity questioaire. Fam Pract 1992; 9: Dickiso J, Hutto S, Atki A, Joes K. Reducig asthma morbidity i the commuity: the effect of a targeted urse-ru asthma cliic i a Eglish geeral practice. Respir Med 1997; 91: Powell C, Everard M. Treatmet of childhood asthma. Optios ad ratioale for ihaled therapy. Drugs 1998; 55: Ordoez G, Phela P, Olisky A, Robertso C. Prevetable factors i hospital admissios for asthma. Arch Dis Child 1998; 78:

6 PREDICTORS OF POOR COMPLIANCE IN ASTHMATIC CHILDREN Leickly F, Wade S, Crai E, Kruszo-Mora D, Wright E, Evas R. Self-reported adherece, maagemet behavior, ad barriers to care after a emergecy departmet visit by ier city childre with asthma. Pediatrics 1998; 101: E Sears M, Burrows B, Flaery E, Herbiso G, Holdaway M. Atopy i childhood. I. Geder ad allerge related risks for developmet of hay fever ad asthma. Cli Exp Allergy 1993; 23: Fitzclarece C, Hery R. Validatio of a asthma kowledge questioaire. J Paediatr Child Health 1990; 26: Clark N, Evas D, Zimmerma B, Leviso M, Mellis R. Patiet ad family maagemet of asthma: theory-based techiques for the cliicia. J Asthma 1994; 31: Meijer A, Griffioe RW, va Nierop JC, Oppeheimer L. Itractable or ucotrolled asthma: psychosocial factors. J Asthma 1995; 32: Cha P, DeBruye J. Paretal cocer towards the use of ihaled therapy i childre with chroic asthma. Pediatr It 2000; 42: Russell G. Ihaled corticosteroid therapy i childre: a assessmet of the potetial for side effects. Thorax 1994; 49: Joes A, Pill R, Adams S. Qualitative study of views of health professioals ad patiets o guided self maagemet plas for asthma. BMJ 2000; 321: Ferguso AE, Gibso NA, Aitchiso TC, Pato JY. Measured brochodilator use i preschool childre with asthma. BMJ 1995; 310: Keeley D, Silverma M. Are we too ready to diagose asthma i childre? Thorax 1999; 54: Joes P. Health status, quality of life ad compliace. Eur Respir Rev 1998; 8: Apter A, Reisie S, Affleck G, Barrows E, ZuWallack R. Adherece with twice-daily dosig of ihaled steroids. Socioecoomic ad health belief differeces. Am J Respir Crit Care Med 1998; 157: Rad C, Butz A. Psychosocial ad behavioral risk factors i asthma maagemet. Semi Respir Crit Care Med 1998; 19: Partridge M. Asthma: lessos from patiet educatio. Patiet Educ Cous 1995; 26: Tettersell MJ. Asthma patiets9 kowledge i relatio to compliace with drug therapy. J Adv Nurs 1993; 18: Kolbe J, Vamos M, James F, Elkid G, Garrett J. Assessmet of practical kowledge of selfmaagemet of acute asthma. Chest 1996; 109: