This website has long been concerned with people not taking their medicine, particularly for asthma. Thus we were instantly drawn to an editorial in JACI In Practice entitled “The Hidden Story of Nonadherence with Asthma Therapy: For a Few Dollars More?” by Dr. Job F.M. van Boven, PharmD, PhD from the Netherlands and Kenneth R. Chapman, MD, from Canada, which among other things critiques both medical practice, patient behavior, and health care policy in wealthier countries, focusing on a study in Australia, covered in the same issue. So we wrote to one of the authors to see if he would answer a few questions.
AAC: Thank you, Dr. van Boven, for taking time for our readers. First, how did you come to write this editorial? Did the editors of In Practice send you the Australia study? Did they send it to both you and Dr. Chapman, or did the two of you decide to collaborate?
Dr. van Boven: It is my pleasure, thank you. Regarding your question, it was actually the editor-in-chief of In Practice, prof. Michael Schatz, who invited the both of us. Indeed, he shared the article with us and subsequently asked us to write the editorial together and put the Australian article on cost-related underuse of asthma medication in a broader perspective. Given our complementary knowledge on this subject, this collaboration worked out very well.
AAC: A few years ago, we covered a study done in the Netherlands that showed roughly three quarters of patients failed to complete their courses of allergy shots (the results for sub-lingual immunotherapy were even lower). Is nonadherence a particular concern of the Dutch medical community?
Dr. van Boven: I remember that SCIT/SLIT adherence study, published in JACI, was it? Indeed, nonadherence is a concern in the Dutch medical community, yet I wouldn’t want to say we are unique in that sense. Nonadherence is a pressing global issue. The World Health Organization estimates that worldwide only around 50% of medications are taken correctly. As a result, people may end up in hospital more frequently than necessary, not only increasing the clinical burden but also the economic burden.
AAC: Returning to your editorial, you wrote that nonadherence because of things like fear of steroids is well studied but that cost is not. Why is cost less studied? I read years ago that it’s a factor in Canada where your co-author lives. Is that still the case? Policy makers in the US look to imports from Canada to relieve our own disastrous medication costs, which Canadians can’t like. And of course, your editorial was a response to the Australia study. How high are the costs to consumers in some of these countries, which have much more comprehensive medical coverage?
Dr. van Boven: I think the reason that costs are less studied is that this factor is hard to measure. The costs of medicines vary from drug to drug, by a country’s health system, health plan, and even over time. The same goes for the exact amount of co-payment that patients have to bear. In the Netherlands, medical coverage is quite extensive and asthma drugs generally have no co-payments in place yet on an annual basis, the first €350 of healthcare costs (including medications but also specialist visits or hospital visits for any reasons) need to be paid by the patient him/herself. In Belgium, our neighboring country, co-payment for asthma medication is around €5 per prescription. This makes international comparative studies difficult. Also, as we argue in our editorial, when asking people face-to-face, it may be difficult to distinguish “costs” from other reasons, such as not believing in, or fearing the side effects of, the drug. Reasons for nonadherence could be multiple and also change over the course of a regimen.
AAC: I like your analysis of the “penny wise, pound foolish” elements of cost for standard controller asthma medications, which posits that non-adherence drives patients into higher-cost emergency medical treatment. Do you have any figures on how much of a burden this places on health care budgets in different countries and how does it affect patient outcomes?
Dr. van Boven: In the Netherlands, there are around 8,000 asthma exacerbations annually that often require a multi-day hospital stay (5 days on average). Total expenses on hospital care for asthma cover 37% of the total yearly spending on asthma of €427 million. It is hard to say what will be the exact percentage of nonadherence-related hospitalizations that is potentially preventable, but each hospitalization is a severe burden on asthma patients’ quality of life. Looking beyond asthma medication nonadherence alone, the OECD estimates that in Europe 200,000 deaths and €125 billion could be related to medication non-adherence. For the USA, these numbers are equally worrisome with an estimated 125,000 preventable deaths and $289 billion of costs.
AAC: You also mention the advent of biologics, which are much more expensive than standard controller medications. You point out that because asthma is poorly controlled because of non-adherence, patients may be prescribed these much more expensive drugs, just as they often end up in the emergency department. Aren’t there protocols about the use of these new drugs, or can we just expect prescriptions to skyrocket because people don’t like the cheaper drugs?
Dr. van Boven: You are correct that, in most countries, these biologics cannot just be prescribed without meeting several prerequisites, before prescription and/or reimbursement is allowed. Usually, one of these prerequisites is ruling out uncontrolled asthma due to inhaler nonadherence. However, in daily clinical practice we often don’t have reliable, objective methods available to assess adherence and we therefore often rely on patient self-report, or pharmacy refill records at best. Fortunately, there are exciting developments around “smart” inhalers that connect to smartphone apps and help patients to better self-manage (e.g. by sending reminders and motivational messages), but also provide insights to the clinician on when and how the inhaler was actually used. This could help them make an informed decision on when to prescribe biologics or when to put actually more efforts on improving adherence first. Another, still very preliminary, method is to measure long-term inhaled drug concentrations in human hair. In this way, we may be able to establish, with one single test, whether or not a sufficiently high drug concentration was reached over the last months. In our Center, we are currently working on both smart inhalers as well as the hair method.
AAC: Your editorial is polite but firm in its critique of the weaknesses of asthma care in the real world. Do you expect much response from your colleagues and the larger community of health care practitioners, researchers, and policy makers?
Dr. van Boven: After publication of the editorial, I got some responses from Dutch and Canadian healthcare professionals. For example, our national pharmacist association noticed that an increasing number of people are not filling their prescriptions, in particular the ones that are not fully reimbursed. They expect that 75% of these unfilled prescriptions are not filled due to cost reasons. Extrapolating the Australian results directly to other countries remains however difficult. The thing is that health systems, prices and reimbursement policies vary from country-to-country and even change over time or between sub-populations.
AAC: Could you offer a few words of advice to patients about their use of asthma medication? And could also give some advice to medical practitioners about their patients’ use of the medicines?
Dr. van Boven: To patients: make sure you get proper education on how and when to use your inhaler. All healthcare professionals (doctors, nurses, pharmacists) should be able to provide this. If you experience difficulties, don’t worry; this is completely normal. Using an inhaler is complex and over 70% of people don’t get it right the first time. So if you are in doubt, ask a qualified health professional to help out.
To medical practitioners: To maximize chances of high adherence, try to involve the patient in the initial choice of inhaler (i.e. by shared decision making), tailor it to their needs, skills and preferences and make sure to provide proper education on when and how to use the inhaler. Often, a one-off educational session is not enough, checking inhaler technique and adherence should preferably be a repeat protocol! Inhaler technique should be visually checked (ask the patient to show you) and adherence should be checked as objective as feasible in your setting and optimized with personalized interventions, tailored to the underlying reason(s). The latter advice is especially relevant when a patient has uncontrolled asthma and before you consider the prescription of additional therapy.
AAC: Finally, whose idea was it to use a Clint Eastwood reference in the title?
Dr. van Boven: Haha, Dr. Chapman came up with the first part of the title, yet the Clint Eastwood inspired subtitle was actually my idea.
Job F.M. van Boven PharmD, PhD is Assistant Professor of Drug Utilization Research and Principal Investigator at the Groningen Research Institute for Asthma and COPD (GRIAC) of the University Medical Center Groningen, the Netherlands. Having interest and wide experience in both medication adherence and health economic methods, his mission is to find novel, cost-effective ways to make better use of our respiratory medications in order to maximize both patients’ and societal benefits. Having completed visiting fellowships in Spain, the USA and Australia, he thereby benefits from a large global respiratory network and perspective. He is the founding director of the Medication Adherence Expertise Center of the northern Netherlands (MAECON).