title: A study of a multi-level intervention to improve non-adherence in difficult to control asthma.
abstract: BACKGROUND
  Difficult to control asthma accounts for significant morbidity and healthcare cost, and non-adherence to medication is a common cause. It remains unclear if targeting non-adherence in this population improves healthcare outcomes.
  
  
  METHODS
  All subjects were referred to a Specialist Difficult Asthma Service (60% from Respiratory physicians); poor adherence was identified using prescription refill records for inhaled combination therapy. A sequential 2 phase study examined the effect of identifying and targeting non-adherence to inhaled long-acting β-agonist/inhaled steroid combination therapy; phase 1 - an observational study utilising objective measures of non-adherence to facilitate a medical concordance discussion followed by phase 2, a 12 month prospective single blind randomised controlled trial where subjects with persistent poor adherence were randomised to a nurse-led menu driven intervention.
  
  
  RESULTS
  A total of 239 patients were assessed; 31 of 83 subjects (37%) who were initially non-adherent, significantly improved adherence after concordance interview, with reduced prescribed daily dose of ICS (data p<0.001), rescue prednisolone courses (data, p<0.001) and hospital admissions (data, p=0.006). With the menu driven intervention, adherence also improved (intervention 37.6% to 61.9%, control group 31.7% to 28.8%) with reduced maintenance oral steroid dose in subjects on maintenance steroids.
  
  
  CONCLUSIONS
  Poor adherence in difficult-to control asthma is common, but when identified and targeted can be improved and this is associated with large improvements in important healthcare outcomes. Previous nihilism towards non-adherence in this population is not supported by this study.
authors.affiliation: Centre for Infection and Immunity, Queen's University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Gamble
authors.forename: Michael
authors.initials: M
authors.lastname: Stevenson
authors.forename: Liam G
authors.initials: LG
authors.lastname: Heaney
mesh_terms: D000293:Adolescent; D000328:Adult; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage*; D001249:Asthma / Q000188:drug therapy* / Q000191:economics / Q000503:physiopathology / Q000523:psychology; D002648:Child; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D010348:Patient Care Team; D012017:Referral and Consultation / Q000191:economics / Q000706:statistics & numerical data*; D012648:Self Care / Q000523:psychology / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D018927:Anti-Asthmatic Agents