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J Allergy Clin Immunol. 2014 Dec;134(6):1260-1268.e3. doi: 10.1016/j.jaci.2014.05.041. Epub 2014 Jul 22.

Inhaler reminders improve adherence with controller treatment in primary care patients with asthma.

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Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia. Electronic address:
Department of General Practice, Sydney Medical School (Westmead), University of Sydney, Sydney, Australia.
Faculty of Pharmacy, University of Sydney, Sydney, Australia.
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.
Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
Department of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Md.
Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.



Poor adherence contributes to uncontrolled asthma. Pragmatic adherence interventions for primary care settings are lacking.


To test the effectiveness of 2 brief general practitioner (GP)-delivered interventions for improving adherence and asthma control.


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.


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).


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.


Medication adherence; ambulatory monitoring; antiasthmatic agents; asthma; health communication; intervention studies; treatment effectiveness

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