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Original Research: RESPIRATORY CARE |

Accurate Assessment of AdherenceAssessment of Adherence to Nebulizer Treatments: Self-Report and Clinician Report vs Electronic Monitoring of Nebulizers

Tracey Daniels, MSc; Lynne Goodacre, PhD; Chris Sutton, PhD; Kim Pollard, BSc(hons); Steven Conway, MBBS; Daniel Peckham, MD
Author and Funding Information

From the York Adult Cystic Fibrosis Unit (Ms Daniels), York Teaching Hospital Foundation NHS Trust, York Hospital, York; School of Public Health and Clinical Sciences (Drs Goodacre and Sutton), University of Central Lancashire, Preston; and Leeds Regional Adult Cystic Fibrosis Unit (Ms Pollard and Drs Conway and Peckham), The Leeds Teaching Hospitals NHS Trust, St James’s Hospital, Leeds, England.

Correspondence to: Tracey Daniels, MSc, York Adult Cystic Fibrosis Unit, Ward 34, York Teaching Hospital Foundation NHS Trust, York Hospital, Wigginton Rd, York YO31 8HE, England; e-mail: traceydaniels1@nhs.net


Parts of this article have been presented in abstract form (Hughes TE, Pollard K, Black A, Conway SP, Peckham DG. Reported and objective adherence to nebulised therapy in adults with cystic fibrosis [Abstract S64]. J Cyst Fibros. 2008;7[suppl 2]:256 and Hughes TE, Pollard K, Goodacre L, Sutton C, Conway SP, Peckham D. Variation in bias of self-reported adherence to nebulizers in adults with cystic fibrosis [Abstract S92]. J Cyst Fibros. 2009;8[suppl 2]:370).

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(2):425-432. doi:10.1378/chest.09-3074
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Background:  People with cystic fibrosis have a high treatment burden. While uncertainty remains about individual patient level of adherence to medication, treatment regimens are difficult to tailor, and interventions are difficult to evaluate. Self- and clinician-reported measures are routinely used despite criticism that they overestimate adherence. This study assessed agreement between rates of adherence to prescribed nebulizer treatments when measured by self-report, clinician report, and electronic monitoring suitable for long-term use.

Methods:  Seventy-eight adults with cystic fibrosis were questioned about their adherence to prescribed nebulizer treatments over the previous 3 months. Self-report was compared with clinician report and stored adherence data downloaded from the I-Neb nebulizer system. Adherence measures were expressed as a percentage of the prescribed regimen, bias was estimated by the paired difference in mean (95% CI) patient and clinician reported and actual adherence. Agreement between adherence measures was calculated using intraclass correlation coefficients (95% CI), and disagreements for individuals were displayed using Bland-Altman plots.

Results:  Patient-identified prescriptions matched the medical record prescription. Median self-reported adherence was 80% (interquartile range, 60%-95%), whereas median adherence measured by nebulizer download was 36% (interquartile range, 5%-84.5%). Nine participants overmedicated and underreported adherence. Median clinician report ranged from 50% to 60%, depending on profession. Extensive discrepancies between self-report and clinician report compared with nebulizer download were identified for individuals.

Conclusions:  Self- and clinician-reporting of adherence does not provide accurate measurement of adherence when compared with electronic monitoring. Using inaccurate measures has implications for treatment burden, clinician prescribing practices, cost, and accuracy of trial data.

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