title: Inhaler reminders improve adherence with controller treatment in primary care patients with asthma.
abstract: BACKGROUND
  Poor adherence contributes to uncontrolled asthma. Pragmatic adherence interventions for primary care settings are lacking.
  
  
  OBJECTIVE
  To test the effectiveness of 2 brief general practitioner (GP)-delivered interventions for improving adherence and asthma control.
  
  
  METHODS
  In a 6-month cluster randomized 2 × 2 factorial controlled trial, with GP as unit of cluster, we compared inhaler reminders and feedback (IRF) and/or personalized adherence discussions (PADs) with active usual care alone; all GPs received action plan and inhaler technique training. GPs enrolled patients prescribed combination controller inhalers, with suboptimal Asthma Control Test (ACT) scores (ACT score ≤19). Inhaler monitors recorded fluticasone propionate/salmeterol adherence (covertly for non-IRF groups) and, in IRF groups, provided twice-daily reminders for missed doses, and adherence feedback. PAD GPs received communication training regarding adherence. Outcomes collected every 2 months included ACT scores (primary outcome) and severe exacerbations. Intention-to-treat mixed-model analysis incorporated cluster effect and repeated measures.
  
  
  RESULTS
  A total of 43 GPs enrolled 143 patients with moderate-severe asthma (mean age, 40.3 ± 15.2 years; ACT score, 14.6 ± 3.8; fluticasone propionate dose, 718 ± 470 μg). Over 6 months, adherence was significantly higher in the IRF group than in non-IRF groups (73% ± 26% vs 46% ± 28% of prescribed daily doses; P < .0001), but not between PAD and non-PAD groups. Asthma control improved overall (mean change in ACT score, 4.5 ± 4.9; P < .0001), with no significant difference among groups (P = .14). Severe exacerbations were experienced by 11% of the patients in IRF groups and 28% of the patients in non-IRF groups (P = .013; after adjustment for exacerbation history; P = .06).
  
  
  CONCLUSIONS
  Inhaler reminders offer an effective strategy for improving adherence in primary care compared with a behavioral intervention or usual care, although this may not be reflected in differences in day-to-day asthma control.
authors: Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia. Electronic address: j.m.foster@woolcock.org.au.
authors: Juliet M
authors: JM
authors: Foster
authors: Department of General Practice, Sydney Medical School (Westmead), University of Sydney, Sydney, Australia.
authors: Tim
authors: T
authors: Usherwood
authors: Faculty of Pharmacy, University of Sydney, Sydney, Australia.
authors: Lorraine
authors: L
authors: Smith
authors: Centre for Adolescent Health, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia.
authors: Susan M
authors: SM
authors: Sawyer
authors: Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
authors: Wei
authors: W
authors: Xuan
authors: Department of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Md.
authors: Cynthia S
authors: CS
authors: Rand
authors: Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.
authors: Helen K
authors: HK
authors: Reddel
mesh_terms: D058666:Adrenergic beta-2 Receptor Agonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000420:Albuterol / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000730:Androstadienes / Q000627:therapeutic use*; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy*; D004338:Drug Combinations; D005260:Female; D000068297:Fluticasone-Salmeterol Drug Combination; D058005:General Practitioners; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009330:Nebulizers and Vaporizers / Q000706:statistics & numerical data*; D011320:Primary Health Care; D011369:Professional-Patient Relations; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D058666:Adrenergic beta-2 Receptor Agonists; D000730:Androstadienes; D018927:Anti-Asthmatic Agents; D004338:Drug Combinations; D000068297:Fluticasone-Salmeterol Drug Combination; D005938:Glucocorticoids; D000420:Albuterol
keywords: Medication adherence; ambulatory monitoring; antiasthmatic agents; asthma; health communication; intervention studies; treatment effectiveness