title: Problem solving to improve adherence and asthma outcomes in urban adults with moderate or severe asthma: a randomized controlled trial.
abstract: BACKGROUND
  Improving inhaled corticosteroid (ICS) adherence should improve asthma outcomes.
  
  
  OBJECTIVE
  In a randomized controlled trial we tested whether an individualized problem-solving (PS) intervention improves ICS adherence and asthma outcomes.
  
  
  METHODS
  Adults with moderate or severe asthma from clinics serving urban neighborhoods were randomized to PS (ie, defining specific barriers to adherence, proposing/weighing solutions, trying the best, assessing, and revising) or standard asthma education (AE) for 3 months and then observed for 3 months. Adherence was monitored electronically. Outcomes included the following: asthma control, FEV(1), asthma-related quality of life, emergency department (ED) visits, and hospitalizations. In an intention-to-treat-analysis longitudinal models using random effects and regression were used.
  
  
  RESULTS
  Three hundred thirty-three adults were randomized: 49 ± 14 years of age, 72% female, 68% African American, 7% Latino, mean FEV(1) of 66% ± 19%, and 103 (31%) with hospitalizations and 172 (52%) with ED visits for asthma in the prior year. There was no difference between groups in overall change in any outcome (P > .20). Mean adherence (61% ± 27%) decreased significantly (P = .0004) over time by 14% and 10% in the AE and PS groups, respectively. Asthma control improved overall by 15% (P = .002). In both groups FEV(1) and quality of life improved by 6% (P = .01) and 18% (P < .0001), respectively. However, the improvement in FEV(1) only occurred during monitoring but not subsequently after randomization. Rates of ED visits and hospitalizations did not significantly decrease over the study period.
  
  
  CONCLUSIONS
  PS was not better than AE in improving adherence or asthma outcomes. However, monitoring ICS use with provision of medications and attention, which was imposed on both groups, was associated with improvement in FEV(1) and asthma control.
authors.affiliation: Allergy and Immunology Section, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA. apter@mail.med.upenn.edu
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Apter
authors.forename: Xingmei
authors.initials: X
authors.lastname: Wang
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Bogen
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Rand
authors.forename: Sean
authors.initials: S
authors.lastname: McElligott
authors.forename: Daniel
authors.initials: D
authors.lastname: Polsky
authors.forename: Rodalyn
authors.initials: R
authors.lastname: Gonzalez
authors.forename: Chantel
authors.initials: C
authors.lastname: Priolo
authors.forename: Bariituu
authors.initials: B
authors.lastname: Adam
authors.forename: Sabrina
authors.initials: S
authors.lastname: Geer
authors.forename: Thomas
authors.initials: T
authors.lastname: Ten Have
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use*; D000328:Adult; D001249:Asthma / Q000188:drug therapy* / Q000503:physiopathology* / Q000517:prevention & control; D004636:Emergency Service, Hospital; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D011340:Problem Solving; D011788:Quality of Life; D012129:Respiratory Function Tests; D016896:Treatment Outcome; D014505:Urban Population
chemical_list: D000305:Adrenal Cortex Hormones