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Errors and Adherence to Inhaled Medications in Chinese Adults with COPD

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Abstract

Background

Adherence to inhaled medications is key to chronic obstructive pulmonary disease (COPD) control and management.

Objective

To assess errors and adherence to inhalation therapy in COPD patients, and identify potential factors associated with poor adherence.

Methods

This cross-sectional study was conducted from October 1, 2022, to November 30, 2022, in 24 hospital outpatient departments in different cities of Hunan Province, China. Adherence to inhaled medications was measured using the 10-item Test of Adherence Inventory, and the results were expressed using both descriptive and inferential statistics.

Results

A total of 2218 clinically confirmed adult COPD patients completed the questionnaires, and 1423 patients with more than a 3-month history of inhalation therapy were analyzed. This study found that 61.3% of patients made one or more use errors. Not holding the breath after inhalation or holding the breath for less than 3 s had the highest reporting rate (30.7%). A considerable proportion of patients (66.6%) demonstrated suboptimal adherence to inhaled medications. Patients who resided in rural areas (OR 1.45, 95% CI 1.12–1.88), used dual therapy (OR 1.47, 95% CI 1.05–2.05), and exhibited common use errors (OR 3.02, 95% CI 2.39–3.82) were more likely to present suboptimal adherence. Patients with CAT (Chronic Obstructive Pulmonary Disease Assessment Test) score < 10 (OR 0.73, 95% CI 0.56–0.94), a junior high school education and above (OR 0.73, 95% CI 0.57–0.94), and duration of inhaled medication use > 3 years (OR 0.63, 95% CI 0.47–0.83) were associated with better adherence.

Conclusion

Suboptimal adherence to inhaled medications and many inhalation therapy errors were identified among COPD patients. Common use errors in inhaled medications, CAT score, and education background were predictive of and influenced adherence to inhaled medications. It is necessary to strengthen training in Chinese patients about inhaler use and follow-up intensively with patients throughout treatment, especially for patients with risk factors.

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Data Availability

The data that support the findings of this study are available from the corresponding author, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.

References 

  1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease 2023 report. Available from: https://goldcopd.org/2023-goldreport/. Accessed 15 Nov 2022

  2. GBD Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med, 2020. 8(6): p. 585–596.

  3. Wang C, et al., Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study. The Lancet, 2018. 391(10131): p. 1706-1717.

    Article  Google Scholar 

  4. Borghardt JM, Kloft C, Sharma A, Inhaled therapy in respiratory disease: the complex interplay of pulmonary kinetic processes. Can Respir J, 2018. 2018: p. 2732017.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ferrera, M.C., W.W. Labaki, M.K. Han, Advances in chronic obstructive pulmonary disease. Annu Rev Med, 2021. 72: p. 119-134.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Martinez, F.J., et al., Baseline symptom score impact on benefits of glycopyrrolate/formoterol metered dose inhaler in COPD. Chest, 2017. 152(6): p. 1169-1178.

    Article  PubMed  Google Scholar 

  7. Vogelmeier, C.F., et al., Impact of baseline COPD symptom severity on the benefit from dual versus mono-bronchodilators: an analysis of the EMAX randomised controlled trial. Ther Adv Respir Dis, 2020. 14: p. 1753466620968500.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Lipson, D.A., et al., Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med, 2018. 378(18): p. 1671-1680.

    Article  CAS  PubMed  Google Scholar 

  9. Halpin, D.M.G., et al., Global initiative for the diagnosis, management, and prevention of chronic obstructive lung disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med, 2021. 203(1): p. 24-36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Melani, A.S., et al., Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med, 2011. 105(6): p. 930-8.

    Article  PubMed  Google Scholar 

  11. Molimard, M., Raherison, C., Lignot, S., Balestra, A., Lamarque, S., Chartier, A., Droz-Perroteau, C., Lassalle, R., Moore, N., Girodet. P.O., Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients. Eur Respir J, 2017. 49(2): p. 1601794..

  12. Liang, C.Y., et al., Misuse of inhalers among COPD patients in a community hospital in Taiwan. Int J Chron Obstruct Pulmon Dis, 2018. 13: p. 1309-1316.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Organization, W.H. Adherence to long-term therapies : evidence for action (2003) [edited by Eduardo Sabaté]. [cited Aug 2022; Available from: https://apps.who.int/iris/handle/10665/42682

  14. Chen, R., et al., Association between adherence to maintenance medication in patients with COPD and acute exacerbation occurrence and cost in China: a retrospective cohort database study. Int J Chron Obstruct Pulmon Dis, 2020. 15: p. 963-971.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Moradkhani, B., et al., Association between medication adherence and health-related quality of life in patients with chronic obstructive pulmonary disease. J Pharm Health Care Sci, 2021. 7(1): p. 40.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Moreira, A.T.A., et al., Evidence of the association between adherence to treatment and mortality among patients with COPD monitored at a public disease management program in Brazil. J Bras Pneumol, 2021. 48(1): p. e20210120.

    PubMed  PubMed Central  Google Scholar 

  17. Montes de Oca, M., et al., Adherence to inhaled therapies of COPD patients from seven Latin American countries: the LASSYC study. PLoS One, 2017. 12(11): p. e0186777.

    Article  PubMed  PubMed Central  Google Scholar 

  18. George, M., Adherence in asthma and COPD: new strategies for an old problem. Respir Care, 2018. 63(6): p. 818-831.

    Article  PubMed  Google Scholar 

  19. López-Campos, J.L., E. Quintana Gallego, L. Carrasco Hernández, Status of and strategies for improving adherence to COPD treatment. Int J Chron Obstruct Pulmon Dis, 2019. 14: p. 1503-1515.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Sulaiman, I., et al., Objective assessment of adherence to inhalers by patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2017. 195(10): p. 1333-1343.

    Article  PubMed  Google Scholar 

  21. Plaza, V., A. López-Viña, B.G. Cosio, Test of Adherence to Inhalers. Arch Bronconeumol, 2017. 53(7): p. 360-361.

    Article  PubMed  Google Scholar 

  22. Muneswarao, J., et al., Translation and validation of the Test of Adherence to Inhalers (TAI) questionnaire among adult patients with asthma in Malaysia. J Asthma, 2021. 58(9): p. 1229-1236.

    Article  PubMed  Google Scholar 

  23. Baiardini, I., et al., Validation of the Italian version of the Test of Adherence to Inhalers. J Investig Allergol Clin Immunol, 2020. 30(6): p. 450-452.

    Article  CAS  PubMed  Google Scholar 

  24. Khosravi, S., et al., Cross-cultural adaptation of the Persian version of Test of the Adherence to Inhalers (TAI). Patient Prefer Adherence, 2019. 13: p. 1693-1699.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Meng, W.W., et al., Reliability and validity of the Chinese version of the test of the adherence to inhalers (TAI). Zhonghua Jie He He Hu Xi Za Zhi, 2022. 45(5): p. 423-430.

    CAS  PubMed  Google Scholar 

  26. Bestall, J.C., et al., Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax, 1999. 54(7): p. 581-6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Jones, P.W., et al., Comparisons of health status scores with MRC grades in COPD: implications for the GOLD 2011 classification. Eur Respir J, 2013. 42(3): p. 647-54.

    Article  PubMed  Google Scholar 

  28. Jones, P.W., et al., Development and first validation of the COPD Assessment Test. Eur Respir J, 2009. 34(3): p. 648-54.

    Article  CAS  PubMed  Google Scholar 

  29. Jones, P.W., M. Tabberer, W.H. Chen, Creating scenarios of the impact of COPD and their relationship to COPD Assessment Test (CAT™) scores. BMC Pulm Med, 2011. 11: p. 42.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Press, V.G., et al., Virtual Teach-To-Goal™ adaptive learning of inhaler technique for inpatients with asthma or COPD. J Allergy Clin Immunol Pract, 2017. 5(4): p. 1032-1039.e1.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ding, B., et al., Inhaler usability of a pressurized metered dose inhaler and a soft mist inhaler in patients with COPD: a simulated-use study. Chron Respir Dis, 2019. 16: p. 1479972318787914.

    Article  PubMed  Google Scholar 

  32. Shealy, K.M., et al., Evaluation of the prevalence and effectiveness of education on metered-dose inhaler technique. Respir Care, 2017. 62(7): p. 882-887.

    Article  PubMed  Google Scholar 

  33. Vanderman, A.J., et al., Inhaler misuse in an older adult population. Consult Pharm, 2015. 30(2): p. 92-100.

    Article  PubMed  Google Scholar 

  34. Plaza, V., et al., Validation of the ‘Test of the Adherence to Inhalers’ (TAI) for asthma and COPD patients. J Aerosol Med Pulm Drug Deliv, 2016. 29(2): p. 142-52.

    Article  PubMed  PubMed Central  Google Scholar 

  35. van Boven, J.F., et al., Clinical and economic impact of non-adherence in COPD: a systematic review. Respir Med, 2014. 108(1): p. 103-13.

    Article  PubMed  Google Scholar 

  36. Alexopoulos, E.C., et al., Frequency and risk factors of COPD exacerbations and hospitalizations: a nationwide study in Greece (Greek Obstructive Lung Disease Epidemiology and health ecoNomics: GOLDEN study). Int J Chron Obstruct Pulmon Dis, 2015. 10: p. 2665-74.

    PubMed  PubMed Central  Google Scholar 

  37. Ierodiakonou, D., et al., Adherence to inhalers and comorbidities in COPD patients. A cross-sectional primary care study from Greece. BMC Pulm Med, 2020. 20(1): p. 253.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Unni, E.J., S. Gupta, N. Sternbach, Using the Medication Adherence Reasons Scale (MAR-Scale) in asthma and chronic obstructive pulmonary disease to determine the extent and identify the reasons for non-adherence. Respir Med, 2021. 179: p. 106337.

    Article  PubMed  Google Scholar 

  39. Molimard, M., et al., Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med, 2003. 16(3): p. 249-54.

    Article  CAS  PubMed  Google Scholar 

  40. Duarte-de-Araújo, A., et al., COPD: Analysing factors associated with a successful treatment. Pulmonology, 2020. 26(2): p. 66-72.

    Article  PubMed  Google Scholar 

  41. Bourbeau, J., et al., Benefit/risk profile of single-inhaler triple therapy in COPD. Int J Chron Obstruct Pulmon Dis, 2021. 16: p. 499-517.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Peng, Y., et al., Adherence to inhaled therapy in patients with COPD associated to pneumoconiosis. Int J Chron Obstruct Pulmon Dis, 2021. 16: p. 2697-2706.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Ismaila, A.S., et al., Fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) triple therapy compared with other therapies for the treatment of COPD: a network meta-analysis. Adv Ther, 2022. 39(9): p. 3957-3978.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Long, H., et al., Single-inhaler triple vs single-inhaler dual therapy in patients with chronic obstructive pulmonary disease: a meta-analysis of randomized control trials. Respir Res, 2021. 22(1): p. 209.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements:

We thank Yang Ting’s team at China-Japan Friendship Hospital for their help. And we thank all the 24 hospital staff members for their efforts in collecting the information that was used in this study, and thank the patients who participated in this study, their families, and the medical, nursing, and research staff at the study centers. The 24 hospitals and their responsible persons are Changsha Hospital of Traditional Chinese Medicine (Dan Liu), The Third Hospital of Changsha (Yingqun Zhu), Changsha Central Hospital (Da Liu), The First Affiliated Hospital of Changsha County (Zhe Chen), Hengshan People’s Hospital (Fang Xia), Hunan Finance and Trade Hospital (Wenzhe Yang), The First Affiliated Hospital of Hunan Normal University (Yongliang Jiang), The Seventh Affiliated Hospital of the University of South China (Yinyan Guo), The First Affiliated Hospital of Hunan University of Medicine (Huiming Yin), The Fifth People’s Hospital of Huaihua (Xiang Zhu), The First People’s Hospital of Huaihua (Zhi Xiang), Jingzhou County People’s Hospital of Huaihua City (Kaicai Zheng), Mayang County People’s Hospital of Huaihua City (Lidan Teng), Tongdao County People’s Hospital of Huaihua City (Chunpeng Lei), Yuanling County People’s Hospital of Huaihua City (Wenjuan Fu), Zhongfang County People’s Hospital of Huaihua City (Ping Wang), Lengshuijiang People’s Hospital (Yanhong Li), Longshan County People’s Hospital (Qingping Zeng), The First People’s Hospital of Pingjiang (Zhinan Wu), Shaodong People’s Hospital (Lijun Liu), Xiangtan Central Hospital (Mingyan Jiang), Zhuzhou Central Hospital (Yanchao Liang), Taoyuan People’s Hospital (Huiming Yin), and Linli County People’s Hospital (Ping Yan).

Funding

This work was supported by the National Natural Science Foundation of Hunan Province (No. 2022JJ30060), the Fundamental Research Funds for the Central Universities of Central South University (No. 2021zzts0369), and the Hunan Provincial Innovation Foundation for Postgraduate (CX20210371).

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Authors and Affiliations

  1. Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, Hunan, China

    Jiankang Wu Master, Weiwei Meng Master, Yiming Ma MD, Zhiqi Zhao MD, Ruoyan Xiong MD, Jiayu Wang MD, Rui Zhao MD, Huihui Zeng MD & Yan Chen MD

  2. Research Unit of Respiratory Disease, Central South University, Changsha, China

    Jiankang Wu Master, Weiwei Meng Master, Yiming Ma MD, Zhiqi Zhao MD, Ruoyan Xiong MD, Jiayu Wang MD, Rui Zhao MD, Huihui Zeng MD & Yan Chen MD

  3. Diagnosis and Treatment Center of Respiratory Disease, The Second Xiangya Hospital, Central South University, Changsha, China

    Jiankang Wu Master, Weiwei Meng Master, Yiming Ma MD, Zhiqi Zhao MD, Ruoyan Xiong MD, Jiayu Wang MD, Rui Zhao MD, Huihui Zeng MD & Yan Chen MD

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  1. Jiankang Wu Master
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Contributions

Conception and design: Jiankang Wu, Weiwei Meng, Yiming Ma, Zhiqi Zhao, Ruoyan Xiong, Jiayu Wang, Rui Zhao, Huihui Zeng, Yan Chen. Interpretation of data, statistical analysis, and manuscript writing: Jiankang Wu, Huihui Zeng. Revision of manuscript and administrative, technical, or material support: Huihui Zeng, Yan Chen.

Corresponding authors

Correspondence to Huihui Zeng MD or Yan Chen MD.

Ethics declarations

Ethics Approval and Consent to Participate:

This study was approved by the Clinical Trial and Ethics Committee of the Second Xiangya Hospital of Central South University (LYF2021155) and was performed in accordance with the Declaration of Helsinki. All participants fully understood the information files. Informed consent was obtained from all participants. All experiments were performed in accordance with the relevant guidelines and regulations.

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Not applicable.

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The authors declare that they do not have a conflict of interest.

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Wu, J., Meng, W., Ma, Y. et al. Errors and Adherence to Inhaled Medications in Chinese Adults with COPD. J GEN INTERN MED 39, 69–76 (2024). https://doi.org/10.1007/s11606-023-08378-y

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