Investigation of a cluster of deaths of adolescents from asthma: Evidence implicating inadequate treatment and poor patient adherence with medications

doi:10.1016/0091-6749(89)90361-8

Journal of Allergy and Clinical Immunology

Volume 84, Issue 4, Part 1, October 1989, Pages 484-491

https://doi.org/10.1016/0091-6749(89)90361-8 Get rights and content

Abstract

We investigated a cluster of five deaths of adolescents from asthma in St. Louis during a 3-month period in 1987. Although the cluster represented a statistically significant increase in the number of asthma deaths in this age group over that observed in previous years, no common exposure to environmental, infectious, or therapeutic agents could be identified. The patterns of hospital admissions for asthma and emergency room visits at the two pediatric hospitals in the community did not suggest an increase in the frequency or severity of asthma during this time. Despite the lack of evidence for common exposure, the decedents shared many personal and medical characteristics. All decedents were black patients and were of lower socioeconomic status. All were adolescents and were responsible for regulating their own medication schedules. Lack of appreciation of the severity of their asthma by medical personnel and the patients' families was evident. For example, two patients with severe asthma had not been prescribed inhaled corticosteroids. In addition, the four decedents tested had markedly subtherapeutic or zero serum theophylline levels measured at the time of the fatal episode, even though appropriate amounts of theophylline had been prescribed. Their theophylline levels were substantially lower than levels in patients of the same age observed at the emergency room or hospitalized for asthma during the same time period. Continued efforts to educate adolescent patients, their families, and medical care providers about the treatment of asthma are warranted.

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Adherence tends to decrease over time in all patients,38 and this pattern was seen across both groups. The pattern with asthma control followed the pattern of adherence, suggesting that the improvements in asthma outcomes were related to improved adherence.4,5,8,39–41 Based on the reported minimally important difference of three points for the Asthma Control Test score, only the intervention group had a large enough improvement to be regarded as clinically significant, with an improvement of more than three points across all time periods.42
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We did a randomised controlled trial in patients aged 6–15 years who attended the regional emergency department in Auckland, New Zealand with an asthma exacerbation and were on regular inhaled corticosteroids. Using a simple, unrestricted block randomisation with block sizes of 200, we randomly assigned patients to receive an electronic monitoring device for use with their preventer inhaler with the audiovisual reminder functions either enabled to support adherence to inhaled corticosteroids (intervention group) or disabled (control group). Participants were followed up every 2 months for 6 months. The primary outcomes were adherence to preventive inhaled corticosteroids and number of days absent from school for any reason. Asthma control was assessed as a secondary outcome. All analyses were done in the intention-to-treat population. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613001353785.
The study took place between May 10, 2010, and Feb 26, 2012. We randomly assigned 220 patients, 110 to the intervention group and 110 to the control group. Median percentage adherence was 84% (10th percentile 54%, 90th percentile 96%) in the intervention group, compared with 30% (8%, 68%) in the control group (p<0·0001). The proportion of days absent from school for any reason was 1·9% (10th percentile 0·0%, 90th percentile 7·9%) in the intervention group and 1·7% (0·0%, 8·6%) in the control group. The change in asthma morbidity score from baseline to 6 months was significantly greater in the intervention group than in the control group (p=0·008), with a reduction of 2·0 points from a mean baseline score of 9·3 (SD 2·2) to 7·3 (2·1) in the intervention group, compared with a reduction of 1·2 points from a baseline of 9·2 (2·5) to 8·0 (2·2) in the control group.
Use of an electronic monitoring device with an audiovisual reminder led to significant improvements in adherence to inhaled corticosteroids in school-aged children with asthma. This intervention could be beneficial for the improvement of asthma control in patients for whom poor asthma control is related to poor adherence.
Health Research Council of New Zealand and Cure Kids.
The Impact of Peer Support and mp3 Messaging on Adherence to Inhaled Corticosteroids in Minority Adolescents with Asthma: A Randomized, Controlled Trial
2013, Journal of Allergy and Clinical Immunology: In Practice
Poor adherence to inhaled corticosteroids (ICS) is a critical risk factor contributing to asthma morbidity among low-income minority adolescents.
This trial tested whether peer support group meetings and peer asthma messages delivered via mp3 players improved adherence to ICS.
Low-income African American and/or Hispanic adolescents, ages 11-16 years old, with persistent asthma, and poor (≤48%) adherence to prescription ICS during the 3-week run-in were randomized to intervention or attention control groups (ATG) for the 10-week treatment. During treatment, the intervention arm subjects participated in weekly coping peer group support sessions and received mp3 peer-recorded asthma messages that promoted adherence. The ATG participated in weekly meetings with a research assistant and received an equivalent number of mp3 physician-recorded asthma messages. Adherence was measured by using self-report and the Doser CT, an electronic dose counter. The primary outcome was the difference in adherence at 10 weeks between the 2 arms.
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Improving medication adherence in longitudinal studies is challenging. Peer support and mp3-delivered peer asthma messages may not be of sufficient dose to improve outcomes.
Demographic, socioeconomic, and psychological factors related to medication non-adherence among emergency department patients
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Citation Excerpt :
In addition, many patients report being unable to fill prescriptions written by emergency physicians within 24 h of discharge from the ED (9–17). Although the resultant morbidity and societal costs are difficult to measure, medication non-adherence is clearly a significant public health problem in the ED population (2,4,6–9,18–27). Despite the prevalence of non-adherence among ED patients, associated factors are poorly understood.
Background: Many Emergency Department (ED) visits are related to medication non-adherence; however, the contributing factors are poorly understood. Objectives: To explore the relative contributions of demographic, socioeconomic, and psychological factors to medication non-adherence in an ED population. Methods: This was a cross-sectional analysis enrolling patients with one of three illnesses requiring chronic medication usage (hypertension, diabetes, or seizures). Trained research associates administered a 60-item survey that assessed demographic and socioeconomic information, as well as a variety of psychological factors potentially relevant to adherence (health attitudes, health beliefs, depression, anxiety, social support, and locus of control). Patients rated their overall prescription medication adherence and estimated the number of days in the preceding month on which doses were missed. In addition, treating physicians estimated the degree to which the ED visit was related to medication non-adherence; clinical data were abstracted to help validate patient and physician assessments. The relationships between non-adherence and demographic, socioeconomic, and psychological variables were explored using multivariate statistics and logistic regression. Covariance analysis was performed to validate subscales, and receiver-operator curves were used to define optimal threshold values. Results: A total of 472 patients consented to participate, with good representation for various demographic and socioeconomic groups. Each psychological factor related significantly to both patient and physician ratings of non-adherence (p < 0.05). Of all demographic and socioeconomic factors examined, only current or historical drug use predicted non-adherence. Conclusions: Psychological factors seem to be important determinants of medication non-adherence among ED patients. These data may help define future research directions and interventions.
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Citation Excerpt :
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While asthma is extremely common, fatal and near fatal asthma is rare and often preventable if there is early recognition of symptom progression and appropriate intervention. In the past decade, asthma mortality has progressively declined in association with the widespread use of inhaled corticosteroids and asthma care plans. Management of life threatening asthma requires patient education to ensure the proper use of medications and to enable the patient to recognize when additional therapy for poorly controlled asthma is required. There is some evidence that suggests that the overly aggressive use of asthma medications when treating a severe exacerbation may contribute to morbidity. Because of the risks of air trapping and barotrauma associated with partial airway obstruction, it is best to avoid mechanical ventilation if possible but when this is used, low tidal volumes, longer exhalation times, and permissive hypercarbia can minimize these risks. There is the promise that a better understanding of asthma immunology and severe asthma “phenotypes” will lead to better prevention and therapy.

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^☆: Supported in part by a research grant from the Central Ohio Lung Association and by Allergic Diseases Academy Award K07-00543.

^∗: From the Division of Surveillance and Epidemiologic Studies, Epidemiology Program Office, Centers for Disease Control, Atlanta, Ga.

^∗∗: From the Pulmonary and Allergy/Immunology Divisions, St. Louis Children's Hospital, and the Department of Pediatrics, Washington University School of Medicine, St. Louis, Mo.

^∗∗∗: Clinical Investigations Branch, Division of Respiratory Studies, National Institute for Occupational Safety and Health, Morgantown, W.Va.

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Original articleInvestigation of a cluster of deaths of adolescents from asthma: Evidence implicating inadequate treatment and poor patient adherence with medications☆

Abstract

Chest

J Allergy Clin Immunol

J Allergy

Pediatr Clin North Am

Asthma mortality in New Zealand: a two-year national study

NZ Med J

Fatal asthma

N Engl J Med

Physiologic and psychologic characteristics associated with deaths due to asthma in childhood: a case-controlled study

JAMA