Adherence to biologic agents for the treatment of moderate to severe asthma varies depending on where patients are getting their injections. According to a retrospective study, adherence rates are lower among those who are always treated in a clinic than among those who self-inject at home.
“I think there are several explanations for this, the first hypothesis [being] that for patients who are less likely to be adherent, we will recommend the clinic [not home use]“, said Hayden Bosworth, PhD, professor and vice president of education and research professor in the Department of Medicine, Psychiatry and Behavioral Sciences, School of Nursing, Duke University Medical Center, Durham, North Carolina . Medscape Medical News.
“So I think we need to do a better job of identifying people and matching them to the right drug and then telling primary care doctors that these patients need to be referred to a specialist. The whole process should be based on a shared decision-making and communication between patient and provider to match patients with what will work best for them,” Bosworth emphasized.
The study was published online in The Journal of Allergy and Clinical Immunology: In Practice.
Data from the Data Mart Optum Clinformatics was evaluated for the period from January 1, 2015 to April 30, 2020. A total of 3932 patients were included. The patients were classified into groups according to the site where they received their treatment: the clinical group only (almost 74% of the cohort); the home self-injection group (20%); and the hybrid group (mix of clinical and self-administered; approximately 6%). Biologics used included dupilumab (Dupixent), mepolizumab (NUCALA), benralizumab (Fasenra), and reslizumab (Cinqair). Among these agents, duplilumab, mepolizumab and benralizumab can be administered at home; reslizumab must be administered at a provider facility. For the study, compliance was “the proportion of observed biological dose administrations compared to the expected biological doses received within 6 months of the initial treatment”.
“Adherence to biologics was relatively lower for clinic only (0.75)…compared to home (0.83)…and hybrid (0.83),” Bosworth and colleagues report. . Factors associated with biological compliance also differed by site of administration. For example, in the model adjusted for the clinic-only group, a 10-year increase in age was associated with a 1% higher adherence rate (adjusted rate ratio [aRR] = 1.01; 95% CI, 1.00 – 1.03).
Geographic variation in adherence rates also differed in the clinical group. Adherence was 6% higher in patients from the Midwest (aRR = 1.06; 95% CI, 1.02, 1.1) compared to those from the South. Membership also differed by level of education; among those with a high school diploma or less, the adherence rate was 5% lower (aRR = 0.95; 95% CI, 0.91 to 0.99) than those with a baccalaureate.
Adherence differed only slightly by household income. The adherence rate was 5% higher among those with household incomes below $40,000 compared to those with household incomes between $40,000 and $99,000, the researchers note (aRR = 1.05; 95% CI, 1 – 1.1). Some indicators of asthma severity were also associated with greater compliance in the clinical group only. These included consultation with a specialist in the previous 6 months and the presence of comorbidities, such as depression.
Adherence rates fell as the cost of prescribed biologics increased. There was a 2% decrease in adherence for every $1000 increase in cost (aRR = 0.98; 95% CI, 0.96, 1.00). Among patients whose index asthma season was autumn, the compliance rate was 5% lower than those whose index season was spring (aRR = 0.95; 95% CI, 0.91 – 0.99), note the authors.
Among patients who administered their biologic at home, adherence rates were 16% lower for black patients compared to white patients (aRR = 0.84; 95% CI, 0.72 – 0.99 ). They were 13% lower for Hispanic patients (aRR = 0.87; 95% CI, 0.77, 0.99). Insurance status in the same group also made a difference, with Medicare patients having a 26% lower adherence rate (aRR = 0.74; 95% CI, 0.66 – 0.83) compared to to commercially insured patients.
Conversely, severity indices were associated with higher rates of adherence, including any visit to a specialist in the previous 6 months (aRR = 1.14, 95% CI 1 – 1.29 ) as well as respiratory infections (aRR = 1.09; 95% CI, 1, 1.18).
“Similarly, for hybrid patients, adherence to biologics differed by income [and] socioeconomic status,” Bosworth and colleagues point out. As expected, in patients with dementia, the adherence rate was 33% lower than in patients without dementia (aRR = 0.67; 95% CI, 0.48 – 0.95 ).
In the adjusted model, adherence was not significantly associated with an emergency department (ED) visit of any kind over the course of a year among patients in the clinic-only group or the home group.
However, in the multivariate model, black race, health insurance, and certain comorbidities, such as depression, were associated with a higher risk of visiting the emergency room for 1 year of follow-up in both the clinical group only. and in the home group. “Conversely, in the model fitted for the hybrid subgroup, a 10 percentage point increase in…adherence was associated with a 9% decreased risk for all-cause emergency department visits over one year” (adjusted hazard ratio [aHR] = 0.91; 95% CI, 0.84 – 0.98), note the authors.
In the hybrid group, each 10-year increase in age was also associated with a 27% lower risk of going to the ED (aHR = 0.73; 95% CI, 0.60 – 0.88 ), while having a bachelor’s degree was associated with a 58% lower risk of going to the emergency room compared with a lower level of education (aHR = 0.42; 95% CI, 0. 19 – 0.96).
Conversely, depression was associated with an 81% increased risk of visiting the emergency room (aHR = 1.81; 95% CI, 1.09, 3.02). When asked why seeing a specialist in the previous 6 months had improved adherence, Bosworth felt that patients received more attention when seen in a specialist clinic. “Specialists are also more familiar with these drugs,” he noted, “so the good thing is that patients probably get better advice at a specialist clinic. The bad thing is that you have to go through a lot of obstacles to getting to see a specialist,” he said.
Bosworth also pointed out that it’s not their fault simply because adherence to an organic diet appears to be lower in black and Hispanic patients than in white patients. “Here in the United States, we use race as a ‘catch-all’ for what I think is a more social and contextual issue – access is an issue, cost is an issue, and I also think for black people in particular, it’s a trust issue,” he said.
“So we need to think better about culture and context. We know there are multiple factors that explain non-adherence, and we need to take responsibility for that and not blame the patient,” Bosworth stressed again.
Other factors involved
Ask by Medscape Medical News Commenting on the study, Sabina De Geest, PhD, RN, Chair, Department of Public Health, University of Basel, Switzerland, noted that while the study took into consideration patient demographics and health factors such as insurance, “meso” level factors, or how care is organized within a clinic, were not taken into account. “For example, you might have a clinic where a lot of attention is given to supporting patients in self-management practices and where continuity of care is followed, so if patients don’t show up, they’re called,” De Geest Explain.
These factors in themselves are related to membership, she added. “So if you have a care environment that is very supportive of patients, you will see better compliance,” she pointed out. Investigators were unable to assess differences between centers regarding where patients received their injections, where large center effect differences in the level of patient adherence are often seen. “That doesn’t mean this study isn’t valid — absolutely not,” De Geest noted.
But much of the adherence – or non-adherence – depends on where the patient lives, the accessibility of their care, and the cost of administering the injection at the clinic or at home. – “all the elements that could be looked at to better understand what is driving non-adherence,” she said. She echoed what Bosworth suggested, which is simply to ask patients what their preferences are; whether they are ready to switch from one treatment to another; whether they are ready for injections; and where they prefer to receive their injection, at home or in the clinic.” All of these factors must be taken into account. into consideration,” De Geest said.
“And then you plan your drug treatment, taking patient preferences into account, and that will help patients accept the new treatment and stick with it,” she reiterated.
The study was sponsored by Sanofi US. Bosworth said he has received research grants from the PhRMA Foundation, Sanofi, NIH and the VA, among others, as well as consulting for Sanofi, Novartis, Otsuka, Abbott and others. De Geest has been a consultant for Sanofi and Novartis.
Cabinet J Allergy Clin Immunol, Published online May 28, 2022. Summary
For more news, follow Medscape on Facebook, TwitterInstagram and YouTube.