Pragmatic Trial of Health Care Technologies to Improve Adherence to Pediatric Asthma Treatment: A Randomized Clinical Trial | Asthma | JAMA Pediatrics | JAMA Network
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National Heart, Lung, and Blood Institute.  National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma: Summary Report 2007. Bethesda, MD: National Heart, Lung & Blood Institute; 2007. NIH publication 08-5846.
Apter  A, Bender  B, Rand  C. Adherence. In: Adkinson  NF  Jr, Bochner  BS, Burks  AW,  et al, eds.  Middleton’s Allergy: Principles and Practice.8th ed. New York, NY: Elsevier; 2014:1471-1479.
Kajioka  EH, Itoman  EM, Li  ML, Taira  DA, Li  GG, Yamamoto  LG.  Pediatric prescription pick-up rates after ED visits.  Am J Emerg Med. 2005;23(4):454-458.PubMedGoogle ScholarCrossref
Bender  BG, Pedan  A, Varasteh  LT.  Adherence and persistence with fluticasone propionate/salmeterol combination therapy.  J Allergy Clin Immunol. 2006;118(4):899-904.PubMedGoogle ScholarCrossref
Williams  LK, Peterson  EL, Wells  K,  et al.  Quantifying the proportion of severe asthma exacerbations attributable to inhaled corticosteroid nonadherence.  J Allergy Clin Immunol. 2011;128(6):1185-1191.e2.PubMedGoogle ScholarCrossref
Bender  BG, Rankin  A, Tran  ZV, Wamboldt  FS.  Brief-interval telephone surveys of medication adherence and asthma symptoms in the Childhood Asthma Management Program Continuation Study.  Ann Allergy Asthma Immunol. 2008;101(4):382-386.PubMedGoogle ScholarCrossref
Tunis  SR, Stryer  DB, Clancy  CM.  Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy.  JAMA. 2003;290(12):1624-1632.PubMedGoogle ScholarCrossref
Sullivan  P, Goldmann  D.  The promise of comparative effectiveness research.  JAMA. 2011;305(4):400-401.PubMedGoogle ScholarCrossref
Andrade  SE, Kahler  KH, Frech  F, Chan  KA.  Methods for evaluation of medication adherence and persistence using automated databases.  Pharmacoepidemiol Drug Saf. 2006;15(8):565-574.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001-2009.  MMWR Morb Mortal Wkly Rep. 2011;60(17):547-552.PubMedGoogle Scholar
Sloan  CD, Gebretsadik  T, Wu  P, Mitchel  EF, Hartert  TV.  Reactive versus proactive patterns of inhaled corticosteroid use.  Ann Am Thorac Soc. 2013;10(2):131-134.PubMedGoogle ScholarCrossref
Vanelli  M, Pedan  A, Liu  N, Hoar  J, Messier  D, Kiarsis  K.  The role of patient inexperience in medication discontinuation: a retrospective analysis of medication nonpersistence in seven chronic illnesses.  Clin Ther. 2009;31(11):2628-2652.PubMedGoogle ScholarCrossref
Vaidya  V, Gupte  R, Balkrishnan  R.  Failure to refill essential prescription medications for asthma among pediatric Medicaid beneficiaries with persistent asthma.  Patient Prefer Adherence. 2013;7:21-26.PubMedGoogle ScholarCrossref
Oake  N, Jennings  A, van Walraven  C, Forster  AJ.  Interactive voice response systems for improving delivery of ambulatory care.  Am J Manag Care. 2009;15(6):383-391.PubMedGoogle Scholar
Marcano Belisario  JS, Huckvale  K, Greenfield  G, Car  J, Gunn  LH.  Smartphone and tablet self management apps for asthma.  Cochrane Database Syst Rev. 2013;11:CD010013.PubMedGoogle Scholar
Choo  PW, Rand  CS, Inui  TS,  et al.  Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy.  Med Care. 1999;37(9):846-857.PubMedGoogle ScholarCrossref
Hansen  RA, Kim  MM, Song  L, Tu  W, Wu  J, Murray  MD.  Comparison of methods to assess medication adherence and classify nonadherence.  Ann Pharmacother. 2009;43(3):413-422.PubMedGoogle ScholarCrossref
Grymonpre  R, Cheang  M, Fraser  M, Metge  C, Sitar  DS.  Validity of a prescription claims database to estimate medication adherence in older persons.  Med Care. 2006;44(5):471-477.PubMedGoogle ScholarCrossref
Ndubuka  NO, Ehlers  VJ.  Adult patients’ adherence to anti-retroviral treatment: a survey correlating pharmacy refill records and pill counts with immunological and virological indices.  Int J Nurs Stud. 2011;48(11):1323-1329.PubMedGoogle ScholarCrossref
Vollmer  WM, Xu  M, Feldstein  A, Smith  D, Waterbury  A, Rand  C.  Comparison of pharmacy-based measures of medication adherence.  BMC Health Serv Res. 2012;12:155-162.PubMedGoogle ScholarCrossref
American Academy of Family Physicians; American Academy of Pediatrics; American College of Physicians; American Osteopathic Association. Joint principles of the patient-centered medical home, March 2007. Accessed June 1, 2014.
Original Investigation
April 2015

Pragmatic Trial of Health Care Technologies to Improve Adherence to Pediatric Asthma Treatment: A Randomized Clinical Trial

Author Affiliations
  • 1Division of Pediatric Behavioral Health, National Jewish Health, Denver, Colorado
  • 2University of Colorado, Denver
  • 3Kaiser Permanente Colorado Institute for Health Research, Denver
  • 4Johns Hopkins Medical School, Baltimore, Maryland
  • 5Kaiser Permanente Center for Health Research Northwest, Portland, Oregon
JAMA Pediatr. 2015;169(4):317-323. doi:10.1001/jamapediatrics.2014.3280

Importance  Most patients with asthma take fewer than half of prescribed doses of controller medication. Interventions to improve adherence have typically been costly, impractical, and at best only minimally successful.

Objective  To test a speech recognition (SR) intervention to improve adherence to pediatric asthma controller medication.

Design, Setting, and Participants  The Breathe Well study was a 24-month pragmatic randomized clinical trial. The study was conducted within Kaiser Permanente Colorado, a large, group-model health maintenance organization. A total of 1187 children aged 3 to 12 years with a persistent asthma diagnosis and prescription for an inhaled corticosteroid were randomized to the computerized SR intervention or usual care condition and followed up for 24 months between October 2009 and February 2013.

Interventions  Speech recognition telephone calls to parents in the intervention condition were triggered when an inhaled corticosteroid refill was due or overdue. Calls were automatically tailored with medical and demographic information from the electronic health record and from parent answers to questions in the call regarding recent refills or a desire to receive help refilling, learn more about asthma control, or speak with an asthma nurse or pharmacy staff member.

Main Outcomes and Measures  Adherence to pediatric asthma controller medication, measured as the medication possession ratio over 24 months.

Results  In the intention-to-treat analysis, inhaled corticosteroid adherence was 25.4% higher in the intervention group than in the usual care group (24-month mean [SE] adherence, 44.5% [1.2%] vs 35.5% [1.1%], respectively; P < .001). Asthma-related urgent care events did not differ between the 2 groups. The intervention effect was consistent in subgroups stratified by age, sex, race/ethnicity, body mass index, and disease-related characteristics.

Conclusions and Relevance  The intervention’s significant impact on adherence demonstrates strong potential for low-cost SR adherence programs integrated with an electronic health record. The absence of change in urgent care visits may be attributable to the already low number of asthma urgent care visits within Kaiser Permanente Colorado. Application of electronic health record–leveraged SR interventions may reduce health care utilization when applied in a population with less-controlled asthma.

Trial Registration Identifier: NCT00958932