1Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
2Immunoalergology, CUF-Porto Hospital and Institute, Porto, Portugal
3Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
4MEDIDA – Medicina, Educação, Investigação, Desenvolvimento e Avaliação, Porto, Portugal
5Serviço de Pneumologia A, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
6Unidade de Imunoalergologia, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
7Imunologia Básica e Clínica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
8Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte EPE, Lisboa, Portugal
9Serviço de Pediatria, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
10Serviço de Pneumologia B, Hospital Geral, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
11Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
12Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
13Pathophysiology, CEDOC, Integrated Pathophysiological Mechanisms Research Group, Nova Medical School, Lisboa, Portugal
14Serviço de Pneumologia, Hospital Beatriz Ângelo, Loures, Portugal
15Serviço de Pediatria, Hospital da Senhora da Oliveira, Guimaraes, Portugal
16Serviço de Imunoalergologia, Hospital Amato Lusitano, Castelo Branco, Portugal
17Serviço de Imunoalergologia, Centro Hospitalar do Algarve EPE, Faro, Portugal
18Serviço de Imunoalergologia, Hospital São João, Porto, Portugal
19University of Beira Interior, CICS - Health Sciences Research Centre; NuESA – Environment & Health Study Group, Faculty of Health Sciences, Covilha, Portugal
20Cova da Beira University Hospital Centre, Department of Allergy & Clinical Immunology, Covilhã, Portugal
21Unidade de Imunoalergologia, Hospital do Divino Espirito Santo de Ponta Delgada EPE, Ponta Delgada, Portugal
22Serviço de Pneumologia, Centro Hospitalar de Trás-os-montes e Alto Douro EPE, Vila Real, Portugal
23Imunoalergologia, Grupo HPA Saúde, Portimao, Portugal
24Serviço de Pneumologia, Centro Hospitalar Barreiro Montijo EPE, Barreiro, Portugal
25Serviço de Pediatria, Centro Hospitalar do Médio Ave EPE, Santo Tirso, Portugal
26Pediatrics, Hospital de Santa Maria, Lisbon, Portugal
27Laboratory of Clinical Pharmacology and Therapeutics, University of Lisbon Medical Faculty, Lisboa, Portugal
28Serviço de Pneumologia, Hospital Garcia de Orta EPE, Almada, Portugal
29Serviço de Pediatria, Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
30Pneumology, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
31NOVA Medical School, Lisbon, Portugal
32Imunoalergologia, Centro de Imunoalergologia do Algarve, Portimão, Portugal
33Serviço de Imunoalergologia, Serviço de Saúde da Região Autónoma da Madeira, Funchal, Portugal
34Serviço de Imunoalergologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
35Bloco operatório, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
36Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), University of Porto Faculty of Medicine, Porto, Portugal
- Publicação em versão integral em BMJ Open 2019;9:e031732. doi:10.1136/bmjopen-2019-031732 9
Objective: We aimed to compare patient’s and physician’s ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.
Design: Baseline data from two prospective multicenter observational studies.
Setting: 29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.
Participants: 395 patients (≥13 years old) with persistent asthma.
Measures: Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0–50; medium 51–80; high 81–100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients’ and physicians’ VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.
Results: High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65–95) mm; 53% VAS>80) and by physicians (84 (68–95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (rs=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV1 ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R2=44%).
Conclusion: Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.
Palavras Chave: asthma, discordance, logistic models, medication adherence.