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“Scared Straight”: Impact of an asthma exacerbation on medication adherence

Published: October 21, 2022

Adherence with daily controller medications in patients with persistent asthma is notoriously poor, and many factors have been found to influence medication adherence in patients with persistent asthma. And, while many studies have looked at a variety of ways to improve medication adherence, few have looked at the effect of an asthma exacerbation on asthma medication adherence.  

In an observational research study recently published in The Journal of Allergy and Clinical Immunology: In Practice, Cvietusa and colleagues from Kaiser Permanente Colorado (KPCO) compared asthma medication adherence, looking at the portion of days covered (PDC), in a cohort of asthma patients 12 months prior to and 12 months after an asthma exacerbation.  Further sub-analysis looked at adherence in patients who had more than one exacerbation after the sentinel exacerbation by type of care received during both periods (primary care, allergist or pulmonologist, or no care), and by socioeconomic status (SES), defined as the lower quartile of the annual income for the group.  

KPCO is integrated health care delivery system composed of direct-pay, employer-sponsored Medicaid, Medicare, and Medicare Advantage insurance plans with more than 550,000 members in the Denver-Boulder metropolitan area. The study looked at patients ages 18 and older with persistent asthma who had had at least one asthma exacerbation during the observed period. An exacerbation was defined as a short course of oral corticosteroids or an emergency department visit or hospitalization where the primary or secondary diagnosis was asthma. Asthma medications included inhaled corticosteroids, oral medications such a leukotriene receptor antagonists, and combination medications with an inhaled corticosteroid and a long-acting form of albuterol. Patients were counted in the specialty care group if they saw a pulmonologist or an allergist, even if they also saw a primary care provider. Within the lower SES population, more than 11% had no high school education, and the median family income was $70,000.

A cohort of 1,697 patients was included in the study. Their PDC improved significantly from 0.44 to 0.53 after an asthma exacerbation. Although adherence showed some decline over time, it ultimately persisted over the 12-month period. Improvement in PDC was even greater if they had more than one exacerbation after the sentinel exacerbation. Being seen by a specialist resulted in the biggest change in medication adherence, over twice as great a change compared to the change seen in those who were not seen by a specialist. Those with a lower SES had lower overall medication adherence but had a similar improvement in their medication adherence after an exacerbation.  

The authors concluded that future studies examining medication adherence should consider controlling for exacerbations during the observation period and that specialty care appears to enhance the improved medication adherence after an exacerbation.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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