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Explore our library of resources below for additional information on the state of pediatric asthma and why BreatheSmart is a smart solution.

Pediatric asthma and adherence in the US

6.1 Million children in the US (8.3% of the child population) have asthma

Out of 6.1 million children with current asthma in the US, 53.7%, or 3.29 million children, reported having one or more asthma attacks.

(Sources:) Centers for Disease Control and Prevention. Asthma; 2016 National Health Interview Survey (NHIS) data. https://www.cdc.gov/asthma/nhis/2016/data.htm. Accessed November 19, 2018. Perry R, Braileanu G, Palmer T, Stevens P. The economic burden of pediatric asthma in the United States: literature review of current evidence [published online ahead of print October 13, 2018]. Pharmacoeconomics. doi:10.1007/s40273-018-0726-2.

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The cost of pediatric asthma hospitalizations in the US was estimated at $1.59 billion, with a total cost of pediatric asthma of approximately $6 billion

Hospitalization and emergency department (ED) costs are a significant healthcare system cost burden. Inpatient costs are in the range of $337-$2,013 per child, per year, while ED costs averaged $152-$172 per child with asthma, per year. Children with asthma have significantly higher healthcare resource utilization and costs than children without asthma.

(Source:) Perry R, Braileanu G, Palmer T, Stevens P. The economic burden of pediatric asthma in the United States: literature review of current evidence [published online ahead of print October 13, 2018]. Pharmacoeconomics. doi:10.1007/s40273-018-0726-2.

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>50% of the childhood asthma population has insufficient control (that’s >3 million children in the US)

More than half of the childhood population (6-16 years) with doctor-diagnosed asthma has insufficient control, according to the Global Initiative for Asthma (GINA) recommendations. As a result of poor asthma control, asthma exacerbations needing hospitalization occur with an estimated incidence of one to two per 1,000 child-years (data from the US).

(Source:) Vasbinder EC, Belitser SV, Souverein PC, et al. Non-adherence to inhaled corticosteroids and the risk of asthma exacerbations in children. Patient Prefer Adherence. 2016;10:531-538.

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For adolescent asthma patients, mean adherence rates to ICS are typically in the range of 49% to 71%

Adherence to asthma medication varies across age groups and with the type of measurement used. Levels of 49%-71% were observed in children and adolescents by objective measurements. Subjective measurements overestimate the level of adherence compared with objective measurements.

(Source:) Desager K, Vermeulen F, Bodart E. Adherence to asthma treatment in childhood and adolescence - a narrative literature review. Acta Clin Belg. 2018;73(5):348-355.

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Mean adherence rate is 55%

A review of studies that measured compliance using electronic monitoring confirmed that the prescribed number of doses per day is inversely related to compliance. Simpler, less frequent dosing regimens resulted in better compliance across a variety of therapeutic classes.

(Source:) Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23(8):1296-1310.

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The optimal level of adherence for good asthma control is >80%

Optimal asthma control entailed an adherence rate higher than 80%.

(Source:) Lasmar L, Camargos P, Champs NS, et al. Adherence rate to inhaled corticosteroids and their impact on asthma control. Allergy. 2009;64(5):784-789.

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As children grow older, their level of adherence reduces, leading to more frequent symptoms and activity limitation

Although older children know more about asthma and assume more responsibility for disease management, their adherence is lower than that of younger children.

In a study sample of children with a wide range of adherence, adherence was negatively related to the functional morbidity index score (r = -.26, p< .01), indicating that the more adherent children were, the less likely they were to experience frequent symptoms and activity limitation.

(Source:) McQuaid EL, Kopel SJ, Klein RB, Fritz GK. Medication adherence in pediatric asthma: reasoning, responsibility, and behavior. J Pediatr Psychol. 2003;28(5):323-333.

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The annual cost to the US healthcare system of medication non-adherence across all diseases was estimated at >$300 billion in 2004

Treatment non-adherence compromises treatment effectiveness and drives up the healthcare costs related to asthma and other chronic conditions. The costs of adherence promotion are outweighed by cost savings after improved adherence, and efforts must support research to develop new and better strategies for improving adherence.

(Source:) Bender BG, Rand C. Medication non-adherence and asthma treatment cost. Curr Opin Allergy Clin Immunol. 2004;4(3):191-195.

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What is causing the issue?

Causes of non-adherence to medication include forgetfulness and inadequate understanding of instructions

In asthma, non-adherence to controller therapy, especially ICS, is common and is likely a factor in poor asthma control. However, non-adherence is often a hidden problem because it is not commonly assessed at routine visits.

Causes of non-adherence can be broken down into two categories: unintentional non-adherence and intentional non-adherence. Unintentional non-adherence results from practical barriers to treatment, such as language barriers, forgetfulness, and inadequate understanding of the instructions.

(Source:) Haughney J, Price D, Kaplan A, et al. Achieving asthma control in practice: understanding the reasons for poor control. Respir Med. 2008;102(12):1681-1693.

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There is a lack of understanding about asthma management among adolescents

Asthma is a common cause of quality of life impairment among high school students. Although specific knowledge on asthma is low, students and teachers hold favourable attitudes towards asthma. There are opportunities to intervene and improve asthma management among adolescents.

(Source:) Gibson PG, Henry RL, Vimpani GV, Halliday J. Asthma knowledge, attitudes, and quality of life in adolescents. Arch Dis Child. 1995;73(4):321-326.

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Parents and children adapt treatment based on symptoms, but have a suboptimal knowledge of asthma management and overestimate the level of asthma control

Many adolescents and parents adapt inhaled corticosteroids use according to the prevalence of asthma symptoms, by reducing or eliminating controller medication in the absence of symptoms. Pediatric asthma patients and their parents tend to overestimate the level of asthma control, either by underestimating asthma severity or by assuming that better control is not possible. The knowledge of parents and adolescents concerning asthma management is suboptimal; moreover, insufficient knowledge about inhaled corticosteroids was linked to poor adherence.

(Source:) Desager K, Vermeulen F, Bodart E. Adherence to asthma treatment in childhood and adolescence - a narrative literature review. Acta Clin Belg. 2018;73(5):348-355.

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As children grow up, the level of supervision from parents and caregivers reduces

Adolescents, or young people between the ages of 10 and 19, are an age group associated with reduced medical supervision from parents and caregivers, as well as with poor adherence to medication (Shah et al, 2001).

(Source:) Howard S, Lang A, Sharples S, Shaw D. See I told you I was taking it! - attitudes of adolescents with asthma towards a device monitoring their inhaler use: implications for future design. Appl Ergon. 2017;58:224-237.

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Children recognize that they forget to take medication

Forgetting to take preventer inhalers was a recognized common factor affecting adherence. The lack of systems to prompt adolescents of the time when preventer inhalers were due to be taken was a particularly relevant barrier.

(Source:) De Simoni A, Horne R, Fleming L, Bush A, Griffiths C. What do adolescents with asthma really think about adherence to inhalers? Insights from a qualitative analysis of a UK online forum. BMJ Open. 2017;7(6):e015245.

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Forgetfulness is also recognized by children, parents, and caregivers as a barrier to medication adherence

In interviews with publicly insured children with asthma, their caregivers, and their primary-care clinicians, every participant was asked to rate the frequency with which he/she believed various barriers to medication use applied to the child on a five-point scale, from never to always. The suggested barriers included: medication runs out, forgetfulness, don’t think they need it, worry about taking medication every day, don’t want to admit they have asthma, too much of a pain, embarrassed, and friends say not to take it.

All groups cited forgetfulness (82% children, 80% caregivers, and 100% clinicians) and medication running out (65% children, 44% caregivers, and 94% clinicians) as top barriers to medication adherence.

(Source:) Arnold CM, Bixenstine PJ, Cheng TL, Tschudy MM. Concordance among children, caregivers, and clinicians on barriers to controller medication use [published online ahead of print February 8, 2018]. J Asthma. doi:10.1080/ 02770903.2018.1424188.

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How can we address the issue?

Strategies for reducing asthma morbidity should include a regular monitoring of adherence to inhaled steroids

In a study of 122 patients with asthma, those with high asthma control typically had high medication adherence (median 85.5% after 4 months of monitoring) compared with those with low asthma control (adherence median 33.8% after 4 months).

(Source:) Lasmar L, Camargos P, Champs NS, et al. Adherence rate to inhaled corticosteroids and their impact on asthma control. Allergy. 2009;64(5):784-789.

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Parents are instrumental in creating a sense of responsibility for adherence

Practical barriers reducing the ability for children to adhere included forgetfulness and poor routine. Prompting and monitoring inhaler treatment by parents were described as helpful, with adolescents benefiting from self-monitoring, for example, by using charts logging adherence. Parents were instrumental in creating a sense of responsibility for adherence.

(Source:) De Simoni A, Horne R, Fleming L, Bush A, Griffiths C. What do adolescents with asthma really think about adherence to inhalers? Insights from a qualitative analysis of a UK online forum. BMJ Open. 2017;7(6):e015245.

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Using electronic monitoring devices is effective

Use of an electronic monitoring device with an audiovisual reminder led to significant improvements in adherence to inhaled corticosteroids in school-age children with asthma

Electronic monitoring devices form a growing area of asthma research, where it has been demonstrated that they offer the most accurate solution for monitoring adherence to asthma therapy (Bender et al, 2000; Burgess et al, 2008; Ingerski et al, 2011). A study in New Zealand demonstrated an 84% compliance level in an intervention group receiving medication reminders, compared with 30% in a control group with no tracking or reminders.

(Source:) Lasmar L, Camargos P, Champs NS, et al. Adherence rate to inhaled corticosteroids and their impact on asthma control. Allergy. 2009;64(5):784-789.

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Children are positive about recording and sharing adherence data

Children are enthusiastic about receving automated reminders to take medication, and use recorded data to demonstrate to their parents or healthcare provider that they are taking their medication properly. Knowledge that parents could view adherence data may have an effect on a child’s medication-taking behavior.

(Source:) Howard S, Lang A, Sharples S, Shaw D. See I told you I was taking it! - attitudes of adolescents with asthma towards a device monitoring their inhaler use: implications for future design. Appl Ergon. 2017;58:224-237.

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Electronic monitoring is an accurate way to measure medication adherence

In a study monitoring adherence of 102 randomly selected asthmatic children and adolescents aged 3-14 years followed for 12 months, canister weight and electronic monitoring measures were more accurate than self/parent reports and pharmacy records. Rates obtained by these two methods were very close, and statistical analysis also showed a substantial agreement between them.

(Source:) Jentzsch NS, Camargos PA, Colosimo EA, Bousquet J. Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods. Allergy. 2009;64(10):1458-1462.

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