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At MD Topical Solutions we are bringing forward the most current education informations available in the world of health care. We are proud to say that our vast library of educational information may one day be the largest depository of health care educational data for specialists as well as for the average person. Our goal is to continually update our content concerning specialists and the medical conditions they face on a daily basis as well as the rare conditions that are not as prevalent.


Asthma is characterised by paroxysmal and reversible obstruction of the airways. It is increasingly understood as an inflammatory condition combined with bronchial hyper-responsiveness. Acute asthma involves:

  • Bronchospasm (smooth muscle spasm narrowing airways)
  • Excessive production of secretions (plugging airways)

Triggers unleash an inflammatory cascade within the bronchial tree leading to the typical symptoms of asthma, e.g. wheeze, shortness of breath, chest tightness, cough. Even in asymptomatic periods, asthmatic lungs show evidence of inflammation compared with controls and there is much interest in how chronic or repeated episodes of inflammation may cause 'remodelling' of the airways and supporting vasculature, leading to disease progression.1

Inflammatory Response

Initially, there is recruitment of leukocytes from the bloodstream to the airway by activated CD4 T-lymphocytes. The activated T-lymphocytes also direct the release of inflammatory mediators from eosinophils, mast cells, and lymphocytes. The subclass 2 helper T-lymphocytes subset of activated T-lymphocytes also produces interleukin (IL)-4, IL-5, and IL-13. IL-4 in conjunction with IL-13 signals the switch from IgM to IgE antibodies. The cross-linkage of two IgE molecules by allergen causes mast cells to degranulate, releasing histamine, leukotrienes, and other mediators that perpetuate the airway inflammation. IL-5 activates the recruitment and activation of eosinophils. The activated mast cells and eosinophils also generate their cytokines that help to perpetuate the inflammation. The repeated cycles of inflammation in the lungs with injury to the pulmonary tissues followed by repair may produce long-term structural changes to the lungs, whatever the trigger.

Acute severe asthma (status asthmaticus) can be life-threatening and the disease causes significant morbidity so it is imperative to treat energetically. The bulk of asthma management has taken place within primary care. Since 2004, it has been an important component of the Qualities and Outcomes Framework of the new General Medical Services


Asthma is best described as a chronic disease that involves inflammation of the pulmonary airways and bronchial hyperresponsiveness. This results in the clinical expression of a lower airway obstruction that usually is reversible. Physiologically, bronchial hyperresponsiveness is shown by decreased bronchial airflow after provocation with methacholine or histamine. Other triggers that provoke airway obstruction include cold air, exercise, viral upper respiratory infection, cigarette smoke and respiratory allergens. Bronchial provocation with allergen induces a prompt early phase immunoglobulin E (IgE)-mediated decrease in bronchial airflow followed (in many patients) by a late-phase IgE-mediated reaction with a decrease in bronchial airflow for 4-8 hours. The gross pathology of asthmatic airways shows lung hyperinflation, smooth muscle hypertrophy, lamina reticularis thickening, mucosal oedema, epithelial cell sloughing, cilia cell disruption, and mucus gland hypersecretion. Microscopically, asthma is characterised by the presence of increased numbers of eosinophils, neutrophils, lymphocytes, and plasma cells in the bronchial tissues, bronchial secretions, and mucus - as shown - obstruction of the lumen of the bronchiole by mucoid exudate, goblet cell metaplasia, epithelial basement membrane thickening and severe inflammation of bronchiole.


  • Undoubtedly, asthma is a very common condition and currently, according to Asthma UK:3
  • 5.4 million people in the UK receive treatment for asthma: 1 in 10 children and 1 in 12 adults.
  • It is the most common chronic medical condition in children.
  • There are 4.1 million GP consultations for asthma per year.
  • The cost of asthma to the NHS runs at about a billion pounds per year.
  • Internationally, the UK is one of the highest ranking countries in terms of asthma prevalence, hospital admissions and mortality.
  • Peak prevalence occurs between the ages of 5 and 15, and falls thereafter until aged 55-64 years, when it starts to rise again.
  • Gender differences - there is a male preponderance in childhood with a reversal in early adulthood.
  • Certain trends in the prevalence of asthma seem apparent over time,4 but their interpretation is difficult, given methodological difficulties (variation in methods of data collection and classification) as well as cultural artefact from changes in the way patients describe respiratory symptoms and the 'ease' with which doctors apply the diagnosis.5
  • Asthma diagnoses have become much more common since the 1950s, with childhood prevalence increased by two to three times. The trend in childhood prevalence appears to have flattened or even fallen recently whilst it remains plateaued in adults.
  • Incidence (based on new asthma diagnoses from the GP) has risen in all ages to a plateau in the 1990s and subsequently fallen.
  • Hospital admission rates rose from the 1960s to the late 1980s and are now falling.
  • There was an asthma death 'epidemic' in the 1960s, particularly amongst children and young adults. This has been ascribed to treatment-related changes. A second, more gradual peak was seen in the 1970s-1980s in adults and mortality has tended to decline since.
The numbers within an individual practice, based on an age/sex/disease register, tend to overestimate true prevalence significantly, as many outgrow asthma without the removal of the diagnosis. It should be changed to past history of asthma when a patient is no longer receiving treatment for the condition.

Overlap between chronic obstructive pulmonary disease and asthma It is well known that chronic obstructive pulmonary disease (COPD) and asthma are almost identical illnesses with similar presentations. Yet there has been recent research which has shown that these two disorders have similar genetic origin and minor changes in the same gene can have positive effects on both asthma and COPD, e.g. matrix metalloproteinase 12.6,7 More work is ongoing in this area.

Risk factors

There is a long list of possible risk factors but research is frequently contradictory or confounded:8

  • Personal history of atopy.9
  • Family history of asthma or atopy.9
  • Inner city environment.
  • Socioeconomic deprivation.
  • Obesity.10
  • Prematurity and low birthweight.
  • Viral infections in early childhood.
  • Maternal smoking.
  • Smoking.11
  • Early exposure to broad-spectrum antibiotics.12
Possible protective factors include: In years to come it may be possible to determine risk by the use of exhaled or genetic biomarkers.15
  • Breast-feeding13
  • Increasing sibship
  • Growing up on a farm14


The history is extremely important as patients may present between acute attacks when examination and investigation may be completely normal. The paroxysmal nature of the condition is important. Wheezing or rhonchi is seen as the cardinal feature but this can be misleading. Ensure that the patient or their parent/carer's understanding of 'wheeze' is the same as yours - whistling, squeaking or gasping sounds, or a different style, rate or timbre of breathing are all sometimes described as 'wheeze' so it is important to clarify. Also, wheeze can be absent in severe asthma when there is insufficient air flow to cause wheeze - beware the silent chest. Ask what happens in an attack. There are a number of possibilities:

  • Wheezing - common but not invariable
  • Coughing
  • Shortness of breath
  • Chest tightness
Ask if there is an obvious precipitating or aggravating factor for attacks:
  • Cold symptoms - upper respiratory tract infection (URTI) - frequently trigger exacerbations.
  • Cold air - if this causes chest pain in an adult, it may be angina.
  • Exercise - symptoms may occur during exercise but more classically after exercise. Running is worse than cycling and it is uncommon when swimming.
  • Pollution - especially cigarette smoke.
  • Allergens - exacerbations may occur seasonally around pollen exposure or following exposure to animals such as cats, dogs or horses.
  • Time of day - there is a natural dip in peak flow overnight and in a vulnerable person this may precipitate or aggravate symptoms. It may cause nocturnal waking or simply being rather short of breath or wheezy in the morning.
  • Work-related - if symptoms are better at home/during holidays, then asthma may be related to occupation. This has significant implications and it is sensible to refer the person to a chest physician or an occupational physician. See separate article Occupational Asthma.
Past, present and family history
  • Atopic eczema, asthma and hay fever tend to run together in individuals and in families.
  • Ask about medication - the patient may have been started on a betablocker recently (including drops for glaucoma) or taken anti-inflammatories. The association between non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, and the precipitation of asthma is well documented but, in reality, it is not often seen.
  • Ask about smoking, including passive smoking.

See separate article Respiratory System - History and Exam. The chest should be examined but this may be normal between attacks:
  • Before examining the chest, check the pulse rate. This may be artificially elevated by excessive use of beta2-agonists but, nevertheless, tachycardia is a significant feature. Respiratory rates above 25/minute and heart rate above 110/minute are regarded as significant signs in adults.9 Where available, also check oxygen saturations in acute attacks (saturations of <92% indicate a more severe subgroup of patients who may require admission).
  • Look at the patient's breathing:
  • Is it fast?
  • Is it laboured?
  • Do they appear anxious?
  • Can they speak in full sentences?
  • Are accessory muscles of respiration employed?
  • Is there pursed lip breathing?
  • Is there cyanosis?
  • Note the ratio between the inspiratory and expiratory phase. Usually this can be assessed by counting one on the way in and one, two on the way out. This 2:1 ratio of expiratory to inspiratory phase is normal. The longer the expiratory phase compared with the inspiratory phase, the more severe the obstruction.
  • The chest may appear hyperinflated.
  • With chronic asthma, there may be chest deformity, e.g. Harrison's sulci. In a small child, there may be intercostal recession with respiratory distress.
  • Check that there is no deviation of the trachea or abnormalities on percussion to suggest pneumonia, pulmonary collapse or pneumothorax.
  • There may be diffuse expiratory rhonchi. If they are not diffuse and particularly if asymmetrical in a child, be suspicious of inhaled foreign body. There may be inspiratory rhonchi too. Where rhonchi are predominantly inspiratory and the inspiratory phase is prolonged, this suggests that airway obstruction is outside the chest.
Differential diagnosis
Asthma is a very common condition but there are many other diagnoses that must be considered: 'not all asthma wheezes and all that wheezes is not asthma'. See separate article Wheezing in Children.

  • Especially if the problem appears to have been present since birth, consider cystic fibrosis. It may also cause severe infections and a persistent cough.
  • Other congenital problems may present from birth or early in infancy, e.g. laryngeal or tracheal structural abnormalities, congenital heart disease.
  • Vomiting and aspiration in babies suggests gastro-oesophageal reflux which can cause a cough on lying down.
  • Inhalation of a foreign body can occur at all ages from the orally curious infant to the performing, older child catching peanuts or grapes in their mouth. Peanuts tend to go straight down to the right main bronchus and cause considerable inflammation, and obstruct the right lower lobe. The choking episode may not have been observed by an adult or may have occurred sufficiently long ago for the family to have forgotten it.
  • Postnasal drip causes a cough, which is worse at night.
  • Inspiratory stridor and wheeze suggest a laryngeal disorder including croup.
  • Focal signs may suggest bronchiectasis or tuberculosis. The latter is very important if the child is from a high-risk family.
  • COPD - reversibility distinguishes asthma from COPD, although the reversibility is relative rather than absolute: people with severe asthma may never achieve completely normal parameters for lung function and COPD is rarely totally refractory to medication. See separate article Diagnosing COPD. Almost all patients with COPD do smoke or have smoked in the past. Asthmatics can also develop COPD. Whether or not this reflects disease progression or comorbidity is debatable.
  • Heart failure can cause nocturnal cough and cardiac asthma.
  • Ischaemic heart disease - chest tightness or pain, especially on meeting a stiff wind on a cold morning - may be asthma or angina.
  • Malignancy is important to remember, especially in smokers. Look for clubbing which also occurs in bronchiectasis. Malignancy is not just lung cancer but may be in the upper airways.
  • Gastro-oesophageal reflux can cause nocturnal cough and a postnasal drip may cause more coughing when lying down.
  • Other less common causes of chronic cough, wheeze or breathlessness include pulmonary fibrosis, interstitial lung disease, recurrent pulmonary embolism and tuberculosis.

Distinguish wheezing from shortness of breath on exertion - this can be due to heart failure, severe anaemia and obesity, often aggravated by lack of physical fitness.

(flow_meter pic)

These are examples of Peak flow meters. They are used to monitor peak expiratory flow rate. The normal values for peak flow vary with sex and height. Increased for male sex and taller height.

Peak flow

Measurement of peak expiratory flow rate (PEFR) is the simplest and most basic test. Every GP should have a mini Wright's peak flow meter with disposable mouthpieces, and a smaller, low reading one is often useful for children and for more severe obstruction. Caution should be used when diagnosing asthma based on peak flow readings but it has an important role in the management of established asthma.

Lung function tests, whether peak flow or spirometry, are unreliable below the age of 5 years and even among some older children and adults who lack comprehension or co-ordination for the task. As well as obstruction of airways, poor effort or neuromuscular disease will limit performance. In those able to use a peak flow meter reliably, it is often helpful to prescribe a peak flow meter for home use to encourage self-monitoring and adjustment of treatment in line with a self-management plan.


  • Peak flow is usually estimated with the patient standing, although results are not significantly different if the patient is seated.16
  • Advise the patient to take in a deep breath and expel it as rapidly and as forcefully as possible into the meter.
  • The very first part is all that matters for this test and it is not necessary to empty the lungs completely.
  • Record the best of three tests. Continue blows if the two largest are not within 40 L/minute, as the patient is still acquiring the technique.

  • Charts of 'normal values' are available. There are different charts for males and females, as males tend to have higher peak flows than females, all other parameters being equal. Expected PEFR increases with increasing height and it varies with age, reaching a peak in the early 20s and then gradually declining. Current normative charts are criticised for being outdated and not encompassing ethnic diversity.
  • A patient's peak flow can be compared with that listed normal for their age, sex and height. However, it is often more helpful in an asthmatic patient to compare changes with an individual's best peak flow, recorded in a clinically stable period on optimal treatment. Thus, a patient with asthma may have a 'predicted' PEFR of 500 L/minute but know that a peak flow of 400 L/minute indicates reasonable control and that, where it falls to 300 L/minute, appropriate action is required.
  • Patients are frequently asked to record a peak flow diary (recording PEFR several times a day over a couple of weeks). It is normal for peak flow to fall slightly overnight and these 'nocturnal dips' may be accentuated in asthma. A marked diurnal variation in peak flow (>20%) is significant. There may be significant day-to-day variation and the patient may be able to demonstrate that testing PEFR after certain aggravating activities causes measurable dips. PEFR is best recorded on a chart which provides graphical illustration of this variability. Peak flow variability is not specific to asthma and so its diagnostic value is debatable.9
  • Reversibility testing can be performed with PEFR testing in subjects with pre-existing obstruction of the airways and is demonstrated by an increase of >60 L/minute.
  • Peak flow diaries may also be helpful for patients with moderate or severe asthma. They can provide an objective warning of clinical deterioration.
(chart pic) This is a spirometry report. The ratio of FEV1 to FVC should be approximately 75–80% in healthy adults. In obstructive diseases (asthma, COPD, emphysema) FEV1 is reduced because of increased airway resistance to expiratory flow. The British Thoracic society has stated that a diagnosis of asthma should be made using a ʻresponse to therapyʼ approach. If the patient responds to treatment, then this is considered to be a confirmation of the diagnosis of asthma. The response measured is the reversibility of airway obstruction after treatment. Airflow in the airways is measured with a peak flow meter or spirometry.

  • Spirometry is now preferred over peak flow measurement for initial confirmation of obstruction of airways in the diagnosis of asthma, as it is felt to offer clearer identification of airway obstruction, to be less effort dependent and more repeatable.9 Spirometry measures the whole volume that may be expelled in one breath (vital capacity). It also permits calculation of the percentage exhaled in the first second (FEV1). However, as with peak flow, some (particularly young children) may not be able to undertake it reliably.
  • Spirometry may be normal in individuals currently asymptomatic and does not exclude asthma and should be repeated, ideally when symptomatic. However, a normal spirogram when symptomatic does make asthma an unlikely diagnosis.
  • It also offers good confirmation of reversibility in subjects with pre-existing obstruction of the airways where a change of >400 mL in FEV1 is found after short-term bronchodilator/longer-term corticosteroid therapy are trialled.
(xray pic) CXR is also used to diagnose complications of asthma. This 5 year old patient has a significant left sided pneumothorax (blue arrow) and partial collapse of the left lung. The patient is slightly rotated, so you cannot comment on any mediastinal shift.


CXR is remarkably normal, even in very severe asthma. It should not be used routinely in the assessment of asthma but consider CXR in any patient presenting with an atypical history or with atypical findings on examination.9

Diagnosis in adults

Current guidelines emphasise that the diagnosis of asthma is a clinical one, based on typical symptoms and signs, and a measurement of airflow obstruction for which spirometry is the preferred initial test. Ascribe high, intermediate or low probability of asthma based on this assessment to determine the use of further investigations or treatment trials.9

Clinical features altering the probability of asthma in adults:9
  • Features increasing the probability
  • Features decreasing the probability
  • Presence of more than one relevant symptom (wheeze, breathlessness, chest tightness and cough), particularly where these are:
  • Worse at night and in the early morning.
  • Triggered by exercise, allergen or cold air.
  • Aspirin or betablocker provoked.
  • A personal or family history of atopy.
  • Widespread wheeze on chest examination.
  • Otherwise unexplained low FEV1 or PEFR.
  • Otherwise unexplained peripheral blood eosinophilia.
  • Prominent dizziness, light-headedness, peripheral tingling.
  • Chronic productive cough without wheeze or breathlessness.
  • Repeatedly normal chest examination when symptomatic.
  • Voice disturbance.
  • Symptoms with colds only.
  • Significant smoking history (>20 pack-years).
  • Cardiac disease.
  • Normal PEFR or spirometry when symptomatic.
Where diagnosis is uncertain (intermediate probability) but with demonstration of airway obstruction ((FEV1)/(FVC) <0.7), reversibility testing and/or a trial of treatment is suggested. Adult patients with normal or near-normal spirometry when symptomatic are likely to have non-pulmonary causes for their symptoms and these should be actively sought.9 Additional investigations of airway obstruction, responsiveness (e.g. histamine or methacholine provocation, exercise or inhaled mannitol challenges) or inflammation (e.g. induced sputum eosinophil count, exhaled nitric acid concentration) may be available through specialists and provide additional diagnostic support in difficult cases but their place in the diagnostic canon remains unclear.9

Diagnosis in children

Diagnosis in children is difficult because of the complex nature of the disorder in the young and is dealt with in the separate article Diagnosing Childhood Asthma in Primary Care. Different 'phenotypes' of wheeze in children are identifiable only in retrospect - episodic viral-induced infant wheeze, some of which may persist/transform into atopic and non-atopic variants of childhood asthma. Also difficulties exist, particularly with younger children obtaining objective evidence of airway obstruction, where they cannot perform peak flow tests or spirometry.

Assessment and review

See separate article Acute Severe Asthma and Status Asthmaticus. All patients with asthma in primary care should be reviewed at least annually and reviews should include:
  • Symptomatic control assessment using a directed question-based tool. Even in practices with good resources, there is a great morbidity from inadequately controlled asthma.17The Royal College of Physicians '3 questions' approach has been widely used and valued for its simplicity, although it is poorly validated:
  • Have you had any difficulty sleeping because of your asthma symptoms, including cough?
  • Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness of breathlessness)?
  • Has your asthma interfered with your usual activities (housework, work, school, etc.)?
  • Alternatives include the Asthma Control Questionnaire, Asthma Control Test and Mini Asthma Quality of Life Questionnaire.
  • Measurement and recording of lung function with peak flow or spirometry.
  • Review of exacerbations in the previous year, use of oral corticosteroids and time of school or work.
  • Check inhaler technique.
  • Check patient compliance and bronchodilator reliance. Review medication use - the use of more than 2 cannisters of reliever per month or 10-12 puffs per day is associated with poorly controlled and higher-risk asthma.
  • Check patient ownership and use of an asthma action plan.
The stepwise approach

See separate articles Management of Adult Asthma and Management of Childhood Asthma. As these are discussed elsewhere, this section will be confined to general principles. The management of asthma is based on 4 principles:
  • Control symptoms, including nocturnal symptoms and those related to exercise.
  • Prevent exacerbations and need for rescue medication.
  • Achieve the best possible lung function (practically FEV1 and/or PEFR >80% predicted or best).
  • Minimise side-effects.
To achieve this:

  • Start at the appropriate step according to the severity of the presenting condition.
  • Achieve early control.
  • Step up or down the medication to enable optimum control without excessive medication. Maintain patients on the lowest possible dose of inhaled steroid. Reduce slowly, with reductions of 25-50%, every 3 months.
  • Always check compliance with current medication, inhaler technique and exclude triggers as far as possible before starting a new drug.
  • Patient education and access to a written personalised action plan are considered critical.

Delivery of drugs to the lungs is a very efficient method in terms of both swiftness of action and limitation of systemic side-effects. However, it is essential to ascertain that the patient is competent at using the inhaler. Simply giving a prescription for a metered dose inhaler (MDI)

(inhaler pic) This is a metered dose inhaler used in asthma. They may be used for prevention and treatment. There are many different types of inhaler devices. The clinician will choose which is most suitable for the patient.

is inadequate; steps must be taken to teach the patient to use the device and to check technique. There are many types of inhaler and they can be used by even the very young. The choice is discussed in the separate article Which Device for Asthma The value of spacers is also discussed, as not only the young have poor co-ordination; spacers may be just as important for adults and the elderly who have difficulties. See separate article Nebulisers in General Practice, discussing their use.

Drug treatment

Current UK guidelines advocate the following, stepwise drug management for adults:9

Step 1 - for those with very mild, intermittent asthma, the occasional use of a beta2 agonist inhaler may be all that is required but all patients with asthma should be prescribed this for short-term relief of symptoms as required.

Step 2 - start regular inhaled steroid at an appropriate dose for the severity of disease (200-800 micrograms/day beclometasone diproprionate or equivalent).

Triggers for starting inhaled corticosteroidsshould be:
  • An exacerbation in the previous 2 years.
  • Use of beta2 agonist inhaler more than 3 times per week.
  • Symptomatic of asthma more than 3 times per week.
  • Waking due to asthma more than once per week.
Step 3 - initial add-on therapy involves the addition of a long-acting beta2 agonist (LABA). These should not be used without the concurrent use of inhaled steroid. Where control is good, continue but where there is no response, stop and increase the dose of inhaled corticosteroid (up to 800 micrograms/day beclometasone diproprionate or equivalent). With partial benefit, continue the LABA but also increase the inhaled corticosteroid dose. If this fails to provide control, trial a leukotriene receptor antagonist or sustained release (SR) theophylline.

Step 4 - with persistent poor control, increase inhaled steroid up to 2,000 micrograms/day beclometasone diproprionate or equivalent and/or add a fourth drug (leukotriene receptor antagonist, SR theophylline or beta2 agonist tablet).

Step 5 - continuous or frequent use of oral steroids, maintaining high-dose inhaled steroids.

Referral to a respiratory physician would be normal at step 4-5 depending on expertise.
Exercise-induced asthma
For most, exercise-induced asthma indicates poorly controlled asthma and will require regular inhaled steroid treatment beyond the anticipatory use of a bronchodilator when preparing for sport. Where exercise poses a particular problem and patients are already on inhaled corticosteroids, consider the addition of long-acting beta agonists, leukotriene inhibitors, chromones, oral beta2 agonists or theophyllines.

Inadequate control of asthma leads to much morbidity and poor quality of life. 12.7 million working days per year are lost to asthma in the UK and there were 77,000 asthma-related emergency admissions in 2005.3 Complications mostly relate to acute exacerbations:
  • Pneumonia
  • Pneumothorax
  • Pneumomediastinum
  • Respiratory failure and arrest
  • Death
Individuals continue to die from asthma (approximately 1,300 deaths in the UK from asthma in 20053). A common feature of deaths from asthma is that the patient and/or the medical staff have underestimated the severity of the attack. Patients frequently have adverse psychosocial factors that interact with the ability to judge or manage their disease, leading to late presentation. A confidential enquiry from the east of England concluded that in two-thirds of asthma deaths, medical management failed to comply with national guidelines. It is suggested that 'at-risk' asthma registers in primary care may improve recognition and management of high-risk


Many children will wheeze early in life (about 30% of those aged under 320) in response to respiratory tract infections but most appear to grow out of it by the time they go to school. A few will continue to wheeze and develop persistent or interval symptoms, similar to older children with atopic asthma. Predictors for continued wheezing include:9
  • Presentation after the age of 2 years.
  • Male sex in prepubertal children.
  • Frequent or severe episodes of wheezing.
  • Personal or family history of atopy.
  • Abnormal lung function.
Some children present with asthma later in childhood and they appear to be less likely to have markers of atopy early in life compared with the persistent early wheezers.21


In order to determine effective primary prevention strategies, we need to unpick the epidemiology of asthma, clearly identify risk and protective factors and come closer to an understanding of asthma's aetiology and changes in prevalence figures. It is striking how little we fully understand about what causes asthma. Whilst family history remains the strongest risk factor for developing atopic asthma, the interplay of the environment is far from clear. The 'hygiene hypothesis' is currently popular. It suggests that decreased exposure to childhood infections, endotoxin and bacteria increases the risk of developing atopy.22 Current guidelines suggest the promotion of breast-feeding (for its other benefits and possible preventative effect) and smoking cessation amongst parents, but evidence for other strategies (e.g.modifying maternal diet during pregnancy, weaning strategies or early aeroallergen avoidance) is lacking.9


1 Fireman P; Understanding asthma pathophysiology. Allergy Asthma Proc. 2003 Mar-Apr;24(2):79-83. [abstract]
2 British Medical Association; Quality and Outcome Framework 2008: summary of indicators (clinical domain)
3 The Asthma Divide, Asthma UK
4 Anderson HR, Gupta R, Strachan DP, et al; 50 years of asthma: UK trends from 1955 to 2004. Thorax. 2007 Jan;62(1):85-90. [abstract]
5 Asthma: statistical information, Lung and Asthma Information Agency; Website for lay people but well presented
6 Hunninghake GM, Cho MH, Tesfaigzi Y, et al; MMP12, lung function, and COPD in high-risk populations. N Engl J Med. 2009 Dec 31;361(27):2599-608. Epub 2009 Dec 16. [abstract]
7 Weiss ST; What genes tell us about the pathogenesis of asthma and chronic obstructive Am J Respir Crit Care Med. 2010 Jun 1;181(11):1170-3. Epub 2010 Feb 4. [abstract]
8 Cates C; Chronic asthma. BMJ. 2001 Oct 27;323(7319):976-9.
9 British Guideline on the Management of Asthma, British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN), 2009
10 Chinn S, Downs SH, Anto JM, et al; Incidence of asthma and net change in symptoms in relation to changes in obesity. Eur Respir J. 2006 Jul 26. [abstract]
11 Frank P, Morris J, Hazell M, et al; Smoking, respiratory symptoms and likely asthma in young people: evidence from postal questionnaire surveys in the Wythenshawe Community Asthma Project (WYCAP). BMC Pulm Med. 2006 May 22;6:10. [abstract]
12 Thomas M, Custovic A, Woodcock A, et al; Atopic wheezing and early life antibiotic exposure: a nested case-control study. Pediatr Allergy Immunol. 2006 May;17(3):184-8. [abstract]
13 Akobeng AK, Heller RF; Assessing the population impact of low rates of breast- feeding on asthma, coeliac disease and obesity: the use of a new statistical method. Arch Dis Child. 2006 Jul 13. [abstract]
14 Riedler J, Braun-Fahrlander C, Eder W, et al; Exposure to farming in early life and development of asthma and allergy: a cross-sectional survey. Lancet. 2001 Oct 6;358(9288):1129-33. [abstract]
15 Gray RD, Duncan A, Noble D, et al; Sputum trace metals are biomarkers of inflammatory and suppurative lung disease. Chest. 2010 Mar;137(3):635-41. Epub 2009 Oct 3. [abstract]
16 Vaswani R, Moy R, Vaswani SK; Evaluation of factors affecting peak expiratory flow in healthy adults: is it necessary to stand up? J Asthma. 2005 Nov;42(9):793-4. [abstract]
17 Jones KP, Bain DJ, Middleton M, et al; Correlates of asthma morbidity in primary care. BMJ. 1992 Feb 8;304(6823):361-4. [abstract]
18 Harrison B, Stephenson P, Mohan G, et al; An ongoing Confidential Enquiry into asthma deaths in the Eastern Region of the UK, 2001-2003. Prim Care Respir J. 2005 Dec;14(6):303-13. Epub 2005 Oct 11. [abstract]
19 Noble MJ, Smith JR, Windley J; A controlled retrospective pilot study of an 'at-risk asthma register' in primary care. Prim Care Respir J. 2006 Apr;15(2):116-24. Epub 2006 Feb 28. [abstract]
20 Piippo-Savolainen E, Korppi M; Wheezy babies--wheezy adults? Review on long-term outcome until adulthood after early childhood wheezing. Acta Paediatr. 2008 Jan;97(1):5-11. Epub 2007 Dec 3. [abstract]
21 Matricardi PM, Illi S, Gruber C, et al; Wheezing in childhood: Incidence, longitudinal patterns and factors predicting persistence. Eur Respir J. 2008 May 14;. [abstract]
22 Liu AH; Hygiene theory and allergy and asthma prevention. Paediatr Perinat Epidemiol. 2007 Nov;21 Suppl 3:2-7. [abstract]


MD Topical Solutions is highly specialized in providing educational materials such as studies in best practices in Aesthetic and Medical compliance via compounded medication. We are dedicated to guiding diverse individuals to a vast network of educational information. Enabling our members to become more competent and confident with their knowledge and skills, thereby improving the overall quality of their lives through personal fulfillment.

The challenge of patient adherence:


Quality healthcare outcomes depend upon patients' adherence to recommended treatment regimens. Patient non adherence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. In some disease conditions, more than 40% of patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice. While no single intervention strategy can improve the adherence of all patients, decades of research studies agree that successful attempts to improve patient adherence depend upon a set of key factors. These include realistic assessment of patients' knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients, and the nurturance of trust in the therapeutic relationship. Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand elements that are crucial to the patient's adherence: beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, particularly depression. Physician–patient partnerships are essential when choosing amongst various therapeutic options to maximize adherence. Mutual collaboration fosters greater patient satisfaction, reduces the risks of nonadherence, and improves patients' healthcare outcomes.

Keywords: patient adherence, health outcomes, physician–patient relationship


For most medical conditions, correct diagnosis and effective medical treatment are essential to a patient's survival and quality of life. A significant barrier to effective medical treatment, however, is the patient's failure to follow the recommendations of his or her physician or other healthcare provider. Patient nonadherence (sometimes called noncompliance) can take many forms; the advice given to patients by their healthcare professionals to cure or control disease is too often misunderstood, carried out incorrectly, forgotten, or even completely ignored. Nonadherence carries a huge economic burden. Yearly expenditures for the consequences of nonadherence have been estimated to be in the hundreds of billions of US dollars (DiMatteo 2004b). Estimates of hospitalization costs due to medication nonadherence are as high as $13.35 billion annually in the US alone (Sullivan et al 1990). In addition to the most obvious direct costs, nonadherence is also a risk factor for a variety of subsequent poor health outcomes, including as many as 125 000 deaths each year (Smith 1989; Burman et al 1997; Christensen and Ehlers 2002; Kane et al 2003).

The corpus of literature on patient adherence is large, and there are many conceptual models that attempt to integrate a large number of complex factors that affect adherence (Bowen et al 2001). To manage the size and complexity of the empirical findings of this massive research enterprise, reliance on meta-analytic work is necessary to provide the building blocks for data-driven models of patient adherence. Currently, ongoing meta-analytic studies at the University of California, Riverside, USA, are beginning to identify a number of stable and consistent factors that affect patient adherence (DiMatteo 2004a, 2004c; DiMatteo et al 2000, 2002). Syntheses of the literature, along with new empirical advances, highlight the complexities inherent in understanding and effecting changes in patient adherence and suggest solutions to common problems in medication management. Much that has been learned from recent research on the communication between healthcare providers and their patients can lessen the economic burden of nonadherence and improve healthcare processes and outcomes for patients.


Research during the past several decades indicates that, depending upon their conditions and the complexity of the regimens required, as many as 40% of patients fail to adhere to treatment recommendations (DiMatteo and DiNicola 1982; DiMatteo 1994, 2004a, 2004c; Lin et al 1995; Rizzo and Simons 1997; Dunbar-Jacob et al 2000; Laederach-Hofmann and Bunzel 2000; Haddad et al 2004; Haynes et al 2004). When preventive or treatment regimens are very complex and/or require lifestyle changes and the modification of existing habits, nonadherence can be as high as 70% (Dishman 1982, 1994; Brownell and Cohen 1995; Katz et al 1998; Chesney 2000; Li et al 2000). Although patients with HIV/AIDS may be highly motivated to adhere, their medication regimens are particularly complex, often involving multiple drug “cocktails” (Catz et al 2000; Heckman et al 2004).

Studies exploring simple versus complex dosing schedules have found that adherence falls off appreciably when regimens become more complicated and affect patients' lifestyles (Chesney 2003). For example, the number of medications to be taken per day can have a significant influence, with adherence rates dropping to as low as 20% among patients who must take thirteen or more pills each day (Graveley and Oseasohn 1991). In one study of patients with hypertension, adherence to a thrice-daily medication regimen was only 59% compared with about 84% for a once-daily regimen (Eisen et al 1990). In another study of patients with severe persistent asthma, only 32% adhered to a regimen that included multiple components such as inhaled and systemic corticosteroids and long-acting bronchodilators (Barr et al 2002).

Adherence to recommendations involving lifestyle changes such as exercise frequently poses significant difficulties for patients. For example, those with chronic illnesses in the Medical Outcomes Study had average adherence rates to exercise regimens of only 19% (Kravitz et al 1993). In another study involving a physical therapy exercise regimen, only 35% of patients adhered fully; 76% followed their prescribed regimen partly but not wholly (Sluijs et al 1993). Such programs, of course, tend to be more successful in supervised rather than home-based programs (McKelvie et al 2002).

The health consequences of nonadherence can be quite severe. Nonadherence compromises patient outcomes in many different ways but is most obvious when patients fail to take medications that likely would cure or at least effectively manage their illnesses (Miller 1997; Chesney et al 2000; Weir et al 2000). For HIV patients who are not at least 90%–95% adherent, viral replication and consequent disease progression may result (Catz et al 2000; Hinkin et al 2002). For patients suffering from or those at risk of coronary heart disease, nonadherence to medication treatments can jeopardize survival (McDermott 1997). Among diabetic patients, adherence to medication for controlling hypertension is essential to preventing mortality from diabetes and myocardial infarction (Elliott et al 2000). Further, aside from direct biomedical benefits, studies show that health may depend partly upon the act of adhering to a regimen. Some research suggests that adherence, even to a placebo, is itself beneficial to health outcomes (McDermott 1997; Irvine et al 1999).

The clinical picture in a patient's treatment can also be confused by nonadherence with patients' risk profiles increased as a result. When physicians erroneously assume that their patients have taken prescribed medication(s), they may make inappropriate medication and/or dosage changes, which can then result in further complications and suboptimal health outcomes. Thus, not only do nonadherent patients fail to benefit from effective medication, they also risk being harmed by less than ideal medication and dosage choices (Joshi and Milfred 1995; Salzman 1995; Bedell et al 2000). Relatedly, the risk of new illness may increase in the context of nonadherence, such as when antibiotic-resistant bacterial infections develop because patients have not taken their full, prescribed doses of antibiotics (Harrison 1995; Lutfey et al 1996; Graham 1998; Rao 1998; Raviglione et al 2001). Thus, it is clear that nonadherence often results in a combination of wasted medical care dollars (Johnson and Bootman 1995; Rizzo and Simons 1997; DiMatteo 2004b), wasted time and energy for patients and healthcare providers alike (DiMatteo et al 1994), and frustration and dissatisfaction for all interactants.

Research on patient adherence

The research literature on patient adherence is extensive. Over the past 50 years, there have been 32 550 adherence related citations in PubMed and 10 087 in PsychLit. Of these citations, more than 2000 represent empirical research articles that involved the assessment of medical patients' adherence to a variety of physician-prescribed regimens (medication, diet, exercise, lifestyle changes, etc).

In this research, as in clinical practice, adherence is measured in a variety of ways including pill counts; self-reports or patient diaries; physician reports; reports by others (such as the patient's spouse); electronic measures (eg, metered dose inhalers or electronic recordings of dispensed eye drops); blood or urine assays; medical record/chart and pharmacy records; and biologic markers (Farmer 1999). These various methods are used in the context of a vast array of disease conditions both chronic and acute. Assessment methods differ in their degree of subjectivity and sophistication, ranging from simple self-reports to more technologically-oriented tools such as the Medication Event Monitoring System (MEMS)™ – an innovative method for measuring adherence in which a hidden microchip mechanism records the time and date that a patient opens a pill box, removes a pill from a pack, actuates an inhaler, or dispenses an eye drop (Farmer 1999). With technologies such as these, every removed dose of medication sends an electronic signal to the physician with the date and time the bottle was opened (Eisen et al 1990), providing a very reliable indicator of medication access (despite the remaining possibility that the dose was removed but not actually taken as prescribed). Direct observation of a patient taking medication is another, albeit more energy-intensive, method for assessing adherence (Volmink et al 2000). In the treatment of latent tuberculosis infection, for example, measurement of adherence to isoniazid (INH) can be direct, using an assessment of INH metabolites in patients' urine (Perry et al 2002; Eidlitz-Markus et al 2003). Pharmacy records represent another resource for measuring adherence. Recent studies have analyzed pharmacy claims databases involving large numbers of patient records and indicating such data as when the medication was obtained and whether prescriptions were refilled on schedule (Tai-Seale et al 2000; Bieszk et al 2003).

Understanding adherence requires a multi-method approach to give a clear and accurate picture of whether and how medical recommendations are being followed. Adherence needs to be measured using multiple tools. For example, adherence to antidepressant medication might be assessed by pill count, patient self-report, and MEMS (Thompson et al 2000; Hamilton 2003). The combination and reconciling of various assessment techniques can be quite valuable, as individual measures of adherence have been shown to differ from one another by as much as 37% (Milgrom et al 1996).

Just as studies of adherence vary greatly in the way they measure the construct, they also range widely in scope and application. Some studies focus on variations in rates of nonadherence (DiMatteo 2004c), some on particular types of nonadherence and their associations with patient outcomes (DiMatteo 2002), others on the correlates of adherence (DiMatteo 2000, 2004a), and still others on the ways clinicians can improve adherence rates for their patients (Roter et al 1998; Atreja et al 2005). Meta-analytic techniques are now being used as well (Macharia et al 1992; DiMatteo et al 2000, 2002; McDonald et al 2002; Peterson 2003; Ismail 2004). Their goal is to synthesize and summarize what we currently know about adherence and to develop data-driven models for understanding the phenomenon and initiating interventions. Such an approach requires careful organization and assessment of the research findings on adherence, seeking evidence for convergence, and stability in research findings. It is clear from the research to date that as we compile and analyze the empirical evidence on patient adherence, we approach an enhanced understanding of this complex and important issue. In this article, we review some of the most robust findings on patient adherence, identifying what we currently know about how to manage and reduce its associated clinical risks in the context of medical practice, as well as what we have yet to determine.

Factors that affect adherence:

Cognitive factors
It goes without saying, perhaps, that patients must understand what they are supposed to do before they can follow medical recommendations. Thus, patients' health literacy is central to their ability to adhere. According to Healthy People 2010, health literacy involves the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (US DHHS 2000, p 20). Studies show that the risk of nonadherence is very high when patients cannot read and understand basic written medical instructions. Misunderstanding of this type is not as uncommon as one might imagine. One large study of over 2500 patients found that nearly one third had marginal or inadequate health literacy. Of these, 42% misunderstood directions for taking medications on an empty stomach, 25% misunderstood the scheduling of their next appointment, and nearly 60% were unable to read and understand a typical informed consent document (Williams et al 1995). Language barriers contributed somewhat to these limitations, but even when patients could understand the language of their medical instructions, many could not comprehend the medical information. Further, older patients in this study had significantly more problems understanding their medical regimens than did younger patients. Other studies confirm these trends and indicate that our current interventions aimed at increasing health literacy to improve patient adherence have, so far, been disturbingly ineffective (Williams et al 1998; Gazmararian et al 1999; Schillinger et al 2003).

Patients' health beliefs are affected by their health literacy, and these beliefs are also contributors to (non)adherence. In a study of asthmatic patients who were given extensive, high-quality information on the use of daily inhaled corticosteroids, only 38% adhered to their medication regimen, whereas the other 62% continued to mistakenly believe that their medication should only be taken when they were symptomatic (Anarella et al 2004). In practice, patients' low health literacy has been linked to ineffective physician–patient communication and, in particular, physicians' failure to assess recall and comprehension of new concepts with their patients (Schillinger et al 2003). Low health literacy has been associated with patient depression (Kalichman 1999) and consequently with the manner in which patients communicate with their doctors. Patient health literacy issues may also be tied to ethnic disparities in screening, such as mammography, probably because of reduced access to and understanding of written cancer prevention materials (Peek and Han 2004).

Another important factor influencing nonadherence is patients' ability to remember the details of the recommendations made to them. Studies have repeatedly shown that forgetting to take (or how to take) medications is a major contributor to nonadherence (Kravitz et al 1993; Cline et al 1999; Brekke et al 2004; Shemesh et al 2004; Zaghloul and Goodfield 2004). Even when information is communicated effectively and comprehension is initially high, much of what is conveyed during the medical visit is forgotten within moments of leaving the doctor's office. One study found that patients forgot 56% of their instructions shortly after leaving the clinic (Ley and Spelman 1965). Optimal verbal communication often does not exist, and the verbal communication between physicians and patients is often filled with technical terms and “medical jargon” that impedes patients' comprehension and retention of information (Jackson 1992). In the interest of time efficiency, details of the prescribed treatment may not be thoroughly explained and/or rehearsed with patients (Stanton 1987), but such clarification is necessary. Healthcare providers need to explain the specific steps of the regimen, review the most important details, use written instructions, and encourage their patients to ask questions about the regimen for adherence to occur (Becker and Maiman 1980; Carter et al 1982; Wolf 1988; Frank et al 1997).

Not surprisingly, when patients are presented with a very large amount of information, they tend to forget a large proportion of it (Ley 1979; Rost et al 1990). High anxiety also contributes to patients' lower levels of recall, and increases the risk of nonadherence (Ley 1979; Shapiro et al 1992; Montgomery 1999). On the other hand, research suggests that the risk of nonadherence is reduced when patients know their doctors well and are in more familiar, and less anxiety-provoking, physician–patient relationships (Rost et al 1990; Heffer et al 1997). Finally, it has been shown that when patients are more satisfied with their medical visits, they tend to experience better recall of information (Falvo and Tippy 1988). Empathic communication involving a thorough understanding of the patient's perspective, improves adherence. Patients who are informed and affectively motivated are also more likely to adhere to their treatment recommendations (Squier 1990). These findings illustrate the importance of the “psychosocial elements” in the medical encounter and their contribution to improving patient adherence to treatment.

Interpersonal factors

The interpersonal dynamics of the physician–patient relationship play an important role in determining a variety of patient outcomes including patient adherence to their treatment recommendations. Patients who feel that their physicians communicate well with them and actively encourage them to be involved in their own care tend to be more motivated to adhere (Frankel 1995; Safran et al 1998; Martin et al 2001; O'Malley et al 2002). Additionally, when physicians and patients agree on how involved patients should be in their care, adherence is improved (Jahng et al 2005). Cohesive partnerships and effective interpersonal communication make it possible for patients and physicians to work together to help patients follow mutually agreed-upon recommendations (Jahng et al 2005). Successful communication between physicians and patients promotes greater patient satisfaction with medical care, which in turn fosters higher levels of adherence.

Patients' trust in their physicians is essential to their emotional disclosure and is therefore a crucial component of the patient–physician relationship. Patients must believe that their physician is someone who can understand their unique experience of being a patient, and someone who can provide them with reliable and honest advice (Branch 2000). Trusting relationships between physicians and patients can greatly affect patient outcomes. For example, it has been shown that physicians who promote trust in the therapeutic relationship, who have effective communication and “bedside manner”, and who express compassion for their patients succeed in fostering cooperation and patient adherence with a variety of preventive and treatment recommendations (O'Malley et al 2002). Adherence rates have been found to be nearly 3 times higher in primary care relationships characterized by very high levels of trust coupled with physicians' knowledge of the patient as a whole person. In fact, patients' trust in their physician has been found to far exceed many other variables when it comes to promoting patients' satisfaction with their care (Safran et al 1998).

Patient involvement and participatory decision making

Studies have found that both patient satisfaction and patient adherence are enhanced by patients' involvement and participation in their care (Martin et al 2001, 2003). The behavior of physicians and patients tends to be reciprocal when they strive toward partnership. Patients who want to be more involved tend to ask more questions and display more confidence, and physicians who are willing to sustain collaborative relationships with their patients tend to act in ways that prompt their patients to be involved and active (Street et al 2003). Research has also shown that patients who participate in discussions of behavioral strategies with their doctor are more likely to adhere to antidepressant medication (Lin et al 1995). Physician–patient partnership and social support from health professionals, as well as from members of the patient's social network, are essential to patients' adherence to recommended treatments (DiMatteo et al 1994; DiMatteo 2004a, 2004c).

This reciprocity and mutuality between patients and their physicians is sometimes termed concordance and is key to greater patient involvement in decision making. When health professional–patient relationships are concordant, patients understand the costs and benefits of their recommended regimens, and through a process of negotiation with their physicians they arrive at a better understanding of treatment. When physicians and patients work together and strive for mutual agreement, they both achieve higher levels of satisfaction with the treatment encounter (Elwyn et al 2003). This reciprocal exchange of information is vital to the decision making process that actively involves the patient (eg, Ong et al 1995). Patients tend to be more satisfied with such exchanges and take more responsibility for and adhere better to treatment choices that are made jointly. Even when dealing with a serious illness such as cancer, most patients have been found to desire all possible information regarding their condition and treatment, even if that information is initially emotionally disturbing to them (Hogbin and Fallowfield 1989; Chaitchik et al 1992). The health professional's willingness to enter this discussion and process of negotiation with patients is critical to subsequent outcomes.

Patients' attitudes

Patients' understanding of their recommendations and good physician–patient relationships are, of course, not sufficient to eliminate the risk of nonadherence. Patients' attitudes, beliefs, and group norms all influence adherence in meaningful and sometimes complex ways. Various cognitive and behavioral models, such as the Theory of Reasoned Action (Ajzen and Fishbein 1980), the Theory of Planned Behavior (Ajzen 1985), and the Transtheoretical Model of Change (Prochaska and DiClemente 1984) demonstrate that people's intentions to carry out a behavior, such as to follow medication treatment, are the immediate precursors to the behavior itself. In other words, intending to adhere, whether this is labeled an intention, a readiness, or a stage of change, is essential to following treatment advice (McCusker et al 1994; Prochaska and Velicer 1997; Willey et al 2000; Hannover et al 2002; Blanchard et al 2003; Anatchkova et al 2005). Intentions, in turn, depend upon what people think and believe, what attitudes they hold, and how other people influence them. Thus, if patients hold beliefs that are incongruent with what their physicians prescribe for them, or if their family or social group members hold divergent views about their illnesses and treatments, patients may have difficulty even forming a willingness or intention to adhere (Greenfield et al 1987; Myers et al 1999; Soliday and Hoeksel 2000; Straughan and Seow 2000). The social environment and the social support available to patients also affect their willingness to adhere, especially when dealing with such conditions as depression, anxiety, HIV, and other illnesses that carry a potential stigma (Roter and Hall 1992; Bensing et al 1995; Kadam et al 2001; Sirey et al 2001).

Cultural variations

Of course, the best way for physicians to facilitate their patients' involvement in care varies across cultures (Calderón and Martin 2003). Preliminary results from our ongoing studies with several ethnic groups in Indonesia demonstrate that interventions aimed at increasing adherence require a multifaceted approach and sophisticated understanding of the complexity of issues involved. Guidelines for improving patient adherence must be tailored to the cultural backgrounds of the individual patients. Although some research has shown positive correlates and outcomes of partnerships when patients and physicians are of the same ethnic background (Cooper-Patrick et al 1999; Saha et al 1999; Cooper et al 2003) other studies have failed to demonstrate this effect and suggest that matching physicians and patients according to their ethnicity is not necessary (eg, Jahng et al 2005). Certainly constructs such as ethnicity, age, and gender are not unimportant, but they interact in very complex ways and may not be as important as communication factors. Recent evidence suggests that physician–patient congruence on their preferences for patient involvement in care is more important than congruence on demographic variables such as ethnicity, age, or gender (Jahng et al 2005). This study evaluated each of these demographic characteristics and found that congruence in preferences for patient involvement was the only significant predictor of self-reported patient adherence, accounting for approximately one fourth of the variance; similarity in age or being of the same ethnicity or gender were unrelated to adherence. These findings illustrate the importance of discussing the physician–patient partnership and together negotiating the patient's role, and suggest that communication (both verbal and nonverbal), partnership and participation, behavior modification strategies, and the prompts and reminders that encourage adherence should be developed uniquely for each individual patient.

In addition to attitudes and sociocultural norms, patients' perceptions of their physicians are also very good predictors of patients' intentions to adhere. In a study we are currently conducting in conjunction with the Bayer Institute for Health Care Communication, our preliminary findings suggest that (in a US sample) patients' intentions to adhere to their recommended treatments are significantly correlated with having choices regarding medical treatments; having the opportunity to discuss their care with their physicians; having their preferences taken into account; and having a doctor who communicates well (all significant at p < 0.001). In addition, preliminary data confirm and extend previous research showing that the amount of trust patients have in their physicians is a strong predictor of whether they plan to carry out treatment recommendations.


In meta-analytic work, findings suggest that one of the strongest predictors of patient nonadherence to medical treatment is patient depression (DiMatteo et al 2000). The risk of patient nonadherence is 27% higher if a medical patient is depressed than if he or she is not (it is 30% higher if that patient has end-stage renal disease). Depression has long been known to predict poor health outcomes, a fact that may be explained partly by the adherence problems caused by depression. Depressed patients experience pessimism, cognitive impairments, and withdrawal from social support, all of which can diminish both the willingness and ability to follow treatment regimens.

Depression is a prevalent and powerful factor in health and illness, and one that cannot be ignored. It is associated with impairment equal to or greater than that of chronic recurrent disorders such as diabetes, hypertension, arthritis, and emphysema (Wells et al 1988, 1989). Depression is currently the most prevalent mental illness and a cause of immense disability in industrialized countries. Major depression is second only to coronary heart disease in functional limitations and serious role impairment (Murray and Lopez 1997; Frasure-Smith and Lespérance 2005). Depression has been cited as the most common clinical problem that primary care physicians are called upon to diagnose and treat. In a given year, in primary care settings, up to 20% of adults present with depression (and often comorbid anxiety) (Greenburg et al 1993; Kirmayer et al 1993).

Psychological disorders are often comorbid with chronic illnesses, increasing their associated morbidity and mortality rates (Brody et al 1995; Waldron 1999; Frasure-Smith and Lespérance 2005). These conditions, however, often go untreated (Young et al 2001). Primary care physicians fail to diagnose as many as 50%–70% of persons who present with current depressive disorder (Higgins 1994; Coyne et al 1995; Lecrubrier 1998; Williams et al 1999; Ballenger et al 2001) despite the potential harm to patients' adherence and health. Even when depression is recognized, it is diagnosed and treated accurately only 30%–40% of the time (Farmer and Griffiths 1992; Kirmayer et al 1993; Rost et al 1994). In the Medical Outcomes Study, 60% of patients with major depression received no medication at all (Wells et al 1994; Sturm et al 1995). Thus, the opportunity to manage major risk factors for nonadherence and for serious patient morbidity and mortality is often missed in primary care.

Why does such a serious risk factor for nonadherence (and other poor healthcare outcomes) so often go unrecognized in the primary care medical interaction? Research suggests that both patients and their physicians contribute jointly to this problem in the medical interaction. Patient factors that prevent recognition of depression in primary care include lack of awareness and understanding of depression symptoms, complaints of physical symptoms that take precedence or confuse the clinical picture, and failure to admit to psychological symptoms because they fear a stigma of mental illness (Docherty 1997). Patients may be reluctant to talk about non-medical matters because they expect physician disinterest or the risk of embarrassment, or because of anxiety about the possible significance of their psychological symptoms (Roter and Hall 1992).

Physician factors can also interfere with the recognition of depression in primary care settings. These include lack of knowledge about the disease, lack of training in the management of depression, reluctance to inquire about their patients' emotional states, and limited time available for patients (Docherty 1997; Carney et al 1999). Indeed, patients' health status can influence the degree of interest and responsiveness they receive. Physicians have been found to convey greater negativity toward physically or mentally less healthy patients and to act more positively toward healthier ones (Hall et al 1996).

Despite many barriers to recognition and treatment, depression continues to play a central role in nonadherence. Appreciation of the importance of patients' mental health in the care of their acute and chronic medical conditions can help to reduce the risks of nonadherence and contribute to more positive health outcomes (Ballenger et al 2001). New and developing models of depression management in primary care show great promise for improving patient commitment to and ultimately the success of medical treatments.

Improving patient adherence

The first step toward improving patient adherence involves accurately assessing whether or not patients have followed the treatments recommended to them. The precise estimation of patient adherence is not easy, and a full understanding of whether and why any given patient chooses and is able to adhere is often elusive. Physicians are typically not well informed about their patients' adherence, and reliance upon their own intuition or upon attempts to “catch” their patients in nonadherence can be quite problematic. Patients tend to be truthful in their adherence reports only when they feel free to admit adherence difficulties without the risk of criticism and in the context of true partnership with their physicians (Haug and Lavin 1981; Hays and DiMatteo 1987). The accurate assessment of adherence depends, to a large degree, on the development of a trusting and accepting relationship between the patient and the healthcare team. Adherence assessments that are simple (presenting as little burden to the respondent as possible) and nonthreatening will also likely yield the most honest and accurate responses.

Realistic assessment of patients' knowledge and understanding of the regimen, and their belief in it, will enable a more effective targeting of the potential for adherence problems. Many of the factors necessary to carry out such assessment are the very elements that foster communication and partnership in the medical visit. Patients need to be given the opportunity to tell their story (Mishler 1984; Smith and Hoppe 1991; Roter and Hall 1992; Roter 2000; Haidet and Paterniti 2003) and to present their point of view to the physician. From this, much information about patients' beliefs, attitudes, subjective norms, cultural contexts, social supports, and emotional health challenges (particularly depression) can be learned. These elements are central to the establishment of adherence intentions, and must be explored and discussed in the therapeutic relationship. Perfect agreement will not always be reached, and in fact may not be desirable. Some degree of conflict between the views of physician and patient may be necessary if truly adult collaboration is to take place and a variety of therapeutic options, and ways to adhere to them, jointly considered (Katz 1984; Wolf 1988). The acknowledgment of differences is an important part of building respectful and trusting relationships between physicians and their patients.

No single intervention strategy can improve the adherence of all patients (Hamilton et al 1993; Cheng et al 1997; Roter et al 1998). Success depends upon tailoring interventions to the unique characteristics of patients, disease conditions, and treatment regimens (McDonald et al 2002). For example, some patients may be unable to maintain a complicated regimen without a strong system of social support and many prompts to remind them of what needs to be done. Other patients may have problems keeping appointments because they do not have access to reliable transportation or because family emergencies arise. Still others may find that side effects of medications are prohibitive or they may simply be unmotivated. The healthcare provider must be attuned to the individual, picking up on subtle hints (verbal and nonverbal) that the patient may express. A flexible mindset in which the physician thinks creatively about treatment options is always an asset. The physician–patient partnership itself, however, remains at the core of all successful attempts to improve adherence behaviors. Participation, engagement, collaboration, negotiation, and sometimes compromise enhance opportunities for optimal therapy in which patients take responsibility for their part of the adherence equation. These partnerships foster greater patient satisfaction, improved patient adherence, and ultimately optimal healthcare outcomes.


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MD Topical Solutions goal is to provide the latest and most efficient software and equipment and to Physician’s offices that may help them overcome a main challenge of rendering the highest quality of care while still generating a profitable business.

Revised Diagnostic Imaging Standards to Take Effect in July 2014

By: Thomas A. Mobilia and Melanie G. Gelfand, Monday, March 31, 2014

The Joint Commission has recently announced new and revised diagnostic standards for accredited hospitals, critical access hospitals and ambulatory healthcare organizations that provide diagnostic imaging services.

Medical experts have emphasized the importance of facilities utilizing diagnostic imaging to take necessary precautions to minimize the risk of radiation exposure. While experts may have differing views on the risks of cancer from diagnostic imaging, there is agreement that care should be taken in weighing the necessity of a given level of radiation against those risks, and steps should be taken to eliminate avoidable radiation exposure and long-term damage.2 The fact that diagnostic imaging has become increasingly available to patients has also meant that the country’s exposure to ionizing radiation has almost doubled in the past 20 years.3 In light of these statistics, many healthcare providers have worked to restructure their radiation safety standards by focusing on areas such as CT protocols, development of incident management policies and procedures, and procurement of new technologies and software to track and monitor radiation dosage.4 The Joint Commission’s new imaging standards will target those states and/or healthcare providers that have yet to adopt such safety measures.

After recognizing the need to more heavily regulate quality and safety issues in radiology, The Joint Commission met with and took recommendations from diagnostic imaging experts, professional associations and accredited organizations to devise these new standards, which not only expand upon the existing requirements but also ensure that imaging protocols remain current.5 This was achieved by focusing on patient safety, including radiation safety, oversight of imaging services, overall staff competency and equipment maintenance.6 According to The Joint Commission Executive Vice President, Margaret VanAmringe, the intended goal is to “ensure that organizations providing imaging services have the requisite infrastructure and safety culture to minimize radiation exposure to patients and staff and provide safe and effective care.”

The safety standards addressed in the prepublication requirements include: (i) managing safety and security risks involving patients with special circumstances, such as claustrophobia or medical implants; (ii) risk management related to hazardous materials and waste, including assessment of staff radiation exposure levels by a radiation safety officer or medical physicist; (iii) annual performance evaluations of all imaging equipment by a diagnostic medical physicist; (iv) mandatory ongoing education for radiologic technologists, including training in radiation dose-reduction techniques; (v) minimum competency for radiology technicians, including registration and certification by July 1, 2015, by either The American Registry of Radiologic Technologists or the Nuclear Medicine Technology Certification Board; (vi) documentation of CT radiation doses in the patient’s clinical record; and (vii) continuing collection of data on radiology incidents and injuries.7

These changes will be implemented in phases. The first phase, which will take effect July 1, 2014, will focus on CT, nuclear medicine, PET and MRI. The second phase is to be implemented by July 1, 2015, and will focus on fluoroscopy, required qualifications for imaging clinicians, and cone beam CT used in dental offices and oral-maxillary surgery practices.

While compliance with these new standards is important for all facilities seeking to maintain The Joint Commission accreditation, it is equally important for the facilities and hospitals that intend continued participation in Medicare and Medicaid reimbursement programs. Since Jan. 1, 2012, Medicare has required that advanced diagnostic imaging — including MRI, CT, PET and nuclear medicine imaging — be billed by those providers which are accredited by one of the Centers for Medicare & Medicaid Services-approved accrediting organizations.8 Hospitals and other imaging facilities will have until July 1, 2014, to meet the newly revised radiation safety rules, or risk losing The Joint Commission accreditation, as well as Medicare and Medicaid participation. It is recommended that the new requirements in the 2014 Ambulatory Care, Critical Access Hospitals, and Hospital Comprehensive Accreditation Manual, published in March, be carefully reviewed in order to ensure up-to-date compliance.9

1. http://www.jointcommission.org
2. Radiation Risks of Diagnostic Imaging, 47 The Joint Commission Sentinel Event Alert 1, (2011) (hereinafter “Sentinel Event Alert”)
3. Neomi Mullens, Are You Ready to Comply with New Radiation Safety Rules?, AuntMinnie.com (February 6, 2014); http://www.auntminnie.com
4. Id.
5. Elizabeth Eaken Zhani, Joint Commission Announces New and Revised Diagnostic Imaging Standards, The Joint Commission (February 6, 2014); http://www.jointcommission.org
6. Zhani, supra note 6
7. See The Joint Commission Prepublication Standards at http://www.jointcommission.org
8. Medicare Coverage of Imaging Services, Department of Health and Human Services: Centers for Medicare & Medicaid Services, June 2013, available at http://www.cms.gov
9. Zhani, supra note 6

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