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Respir Med. 2011 Sep;105(9):1308-15. doi: 10.1016/j.rmed.2011.03.019. Epub 2011 Apr 20.

A study of a multi-level intervention to improve non-adherence in difficult to control asthma.

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Centre for Infection and Immunity, Queen's University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom.



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.


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.


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.


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.

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