Nonadherence to COPD Treatment: What Have We Learned and What Do We Do Next?

Few of us are surprised to learn that half or more of patients with COPD are nonadherent with their medication. Across all chronic health conditions, nonadherence is a problem that undermines attempts to manage the illness, reduce exacerbations, and maintain both length and quality of life. The tougher questions are why are these patients nonadherent, and what can we do to increase treatment adherence. Although those questions have been extensively research in the areas of asthma, diabetes, and cardiovascular disease, similar information about COPD treatments lags well behind. The article by Slatore and associates (1) moves us closer to answering these questions by providing important new information.

In their study, adherence was better with long-acting beta-agonists (LABA) than with inhaled corticosteroids (ICS), perhaps because the former deliver an immediate sense of symptom relief while the latter do not. LABA adherence was better in patients who were older, more educated, and not using tobacco or overusing alcohol, and worse in patients who were Black or treated for co-morbid conditions. Adherence was not associated with marital status, income, or gender.

Most striking was the finding that adherence to both LABAs and ICS was higher where patients perceived their provider as being an “expert.” This positive perception of one's healthcare provider cannot be attributed to amount of education or professional status; type of degree or specialty board certification had no bearing on adherence. The difference between a physician whose treatment is trusted by patients, and one whose is not, often comes down to the quality of the communication between provider and patient. Patients who rated their physicians higher in listening, caring and attentiveness during interactions also reported higher confidence in managing their COPD and higher quality of life (1).

COPD programs that emphasize quality patient-provider communication strategies can lead to better patient care and decreased cost (2). Even the manner in which treatments are described to patients influences their motivation to follow the treatment plan; increasing positive expectations about the medication increases adherence (3), while fueling negative expectations including overemphasis on potential side effects drives down adherence (4).

Patient-centered care includes respecting the patient's values and preferences, and making sure patients have a solid understanding of their illness and treatment (5). When clinicians take the time to understand patients’ preferences and include them in making treatment choices, an approach called “shared decision making,” adherence increases (6).

Sensitivity to the psychological status of patients with COPD is an additional important component of patient-centered care. This includes being watchful for clinical depression, which is present in 25% of COPD patients (7) and associated with decreased adherence (8), increased hospital readmission (9), and increased mortality (10). Although depression was not measured in the Slatore et al. study, other patient characteristics that tend to rise with depression were measured.

Tobacco and alcohol use occurred less frequently among patients with high adherence. It is notable that at the opposite end of the mood spectrum, HIV patients who scored higher on an optimism scale tended to be more adherent, (11) and patients with cardiovascular disease who expressed higher levels of optimism tended to live longer (12). Although any depressed patient should receive treatment for their depression, a secondary benefit may be increased adherence. In one study of patients with multiple sclerosis, the percentage of patients with high medication adherence increased by over 200% following at least 6 months’ of depression treatment (13).

Where do we go from here to address the problem of nonadherence to COPD treatment? Two areas for continued research are evident. First, for COPD patients, medication nonadherence is not the whole story. Pulmonary rehabilitation is an important determinant of COPD quality of life and survival. Distance walked in 6 minutes is a significant predictor of COPD-related hospitalization and death (14). Although exercise nonadherence remains a major barrier to COPD management,15the examination of adherence in COPD treatment has primarily focused on medication use, and little is known about the factors that influence pulmonary rehabilitation adherence, the impact of partial adherence on survival, or the interventions that might lead to longer participation. Second, there is great need to better understand how to activate COPD patients to be more adherent with medications and rehabilitation. Discovery of the correlates of adherence does not invariably lead to effective interventions. For example, the demographic factors that predicted nonadherence in the Slatore et al. (1) study, including age, race, and education level, can't be changed. Even those predictors that might be “modifiable,” including tobacco and alcohol use or self-efficacy, can't be easily addressed by the health care provider. Interventions for tobacco and alcohol use exist, but often fail, and no clear intervention has been identified that can greatly change self-efficacy. Further, the correlation between two variables does not establish that one causes the other. Hence, low self-efficacy may correlate with low adherence, but the underlying cause of the low adherence may be a third variable that correlates with both self-efficacy and adherence, such as anxiety or socioeconomic distress.

This means that more work needs to be done to fully understand how to influence adherence in COPD patients. Innovative approaches to helping COPD patients accept and continue to use effective treatments that enhance life quality and survival, including medications and exercise, must be developed based on well-supported behavior change theories and then tested in randomized trials in multiple clinical settings (16). Until that happens, the basic principles of patient-centered care remain the healthcare provider's best tools for engaging patients to effectively manage their disease.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.