A survey and analysis of inhalation medication adherence among 977 COPD patients in a region of northern China

Abstract

Objective

Inhalation therapy is recommended by the World Health Organization as the first-line treatment for chronic obstructive pulmonary disease (COPD) due to its rapid onset of action, good safety profile, ease of use, and portability. High medication adherence in COPD patients is crucial for enhancing disease management. The aim of this study was to assess the level of disease control, adherence to inhaled medication therapy, and potential factors influencing treatment adherence among COPD patients.

Methods

A paper-based questionnaire was used to survey COPD patients who were outpatients or inpatients at the First Affiliated Hospital of Harbin Medical University between January 2019 and October 2023. Patients were included if they had been diagnosed with stable COPD for more than 12 months, were prescribed inhaled medications for post-consultation or post-discharge management, and had used these medications for at least 8 weeks with follow-up review. Questionnaires were administered at the time of consultation and at the 8-week follow-up to comprehensively evaluate patients’ adherence to inhaled medications based on their medication administration methods, frequency, and other relevant factors. Categorical data were described using frequencies and percentages, and comparisons between groups were conducted using the chi-square test. For the analysis of risk factors, binary logistic regression analysis was employed. To avoid collinearity among variables, a stepwise regression method was utilized for variable selection. A P-value < 0.05 was considered statistically significant.

Results

A total of 977 patients were included, with an average age of 63 ± 9 years. Among them, 40.9% of the patients demonstrated high adherence to inhaled medication therapy. Patients who were under 70 years old (P = 0.03), had a higher annual household income (P = 0.04), had family supervision (P = 0.01), and had medical insurance (P = 0.02) exhibited higher adherence to inhaled medication therapy.

Conclusion

Among the surveyed patients, those who were under 70 years old (OR = 5.1, CI = 1.13–23.11) and had family supervision (OR = 3.26, CI = 1.3–8.21) demonstrated better medication adherence. This suggests that physicians could potentially improve patient medication adherence, optimize disease control, and enhance the overall quality of life for these patients by considering targeted interventions, such as identifying and educating elderly patients, intensifying tailored promotional activities, and encouraging family members to supervise medication use.

Introduction

Chronic obstructive pulmonary disease (COPD), a global health challenge, imposes enormous pressure on public health systems due to its high incidence and disability rates [1, 2]. COPD not only affects patients’ respiratory function but also significantly reduces their quality of life and increases socio-economic burdens [2, 3]. The hallmark symptoms of COPD include persistent dyspnea, which often worsens with increased activity, severely impacting patients’ daily functioning. Cough, particularly exacerbated in the morning or at night, and expectoration, with varying amounts and colors of sputum, are also common symptoms of COPD [2, 4]. Furthermore, COPD patients frequently face challenges during acute exacerbations (AECOPD), where respiratory symptoms rapidly deteriorate within a short period, often necessitating changes in routine treatment regimens to manage the condition. AECOPD not only intensifies patient suffering but also increases healthcare resource consumption and hospitalization risks. With a deeper understanding of the pathophysiological mechanisms of COPD, inhalation therapy has become a cornerstone in COPD management due to its unique advantages, such as direct targeting of the organ, rapid onset of action, and relatively fewer side effects [2]. Adherence to prescribed treatment helps control COPD symptoms [5]; however, to achieve optimal effects of inhalation therapy, patients must follow medical advice, maintain regular medication habits, and master correct inhalation techniques. This necessitates high medication adherence from patients, which is currently a significant challenge in COPD management [6,7,8,9,10]. Medication adherence encompasses not only whether patients take their medication on time and in the correct dosage but also their understanding and acceptance of the treatment plan and its implementation in real life. Studies have shown that medication adherence in COPD patients is influenced by various factors, including but not limited to disease awareness, complexity of treatment regimens, economic burdens, social support, psychological status, proficiency in inhalation techniques, and the quality of physician–patient communication. These factors interact and collectively impact patients’ medication-taking behavior [6, 11,12,13,14,15,16,17].

Due to lifestyle habits, cold climates, and heating through combustion [18, 19], the incidence of COPD is higher in northern China [20, 21]. However, there is currently a lack of data on medication adherence to inhaled therapy among COPD patients in northern China. This study conducted on-site and telephone surveys among confirmed COPD inpatients and outpatients at the First Affiliated Hospital of Harbin Medical University, who have resided in northern China for a long time. Through these data, we deeply analyzed the current status of medication adherence to inhaled therapy among the surveyed COPD patients and various factors that may affect their adherence. The ultimate goal of this study is to provide valuable reference information to clinicians, helping them better understand and improve medication adherence to inhaled therapy among COPD patients in this region, thereby enhancing patients’ treatment outcomes and quality of life.

Methods

Study population

Patients with COPD who visited the outpatient and inpatient departments of the Respiratory Medicine at the First Affiliated Hospital of Harbin Medical University between January 2019 and October 2023 were selected for this study. The inclusion criteria were as follows: patients aged 50–89 years, who underwent pulmonary function testing using the MasterScreen-Body/Diff device manufactured by Jaeger (Germany). According to the GOLD criteria, a diagnosis of COPD was established if the post-bronchodilator forced expiratory volume in 1 s (FEV₁) to forced vital capacity (FVC) ratio was less than 0.7. (GOLD stage I (Mild): FEV1% predicted ≥ 80%; GOLD stage II (Moderate): 50% ≤ FEV1% predicted < 80%; GOLD stage III (Severe): 30% ≤ FEV1% predicted < 50%; GOLD stage IV (Very Severe): FEV1% predicted < 30%, or FEV1% predicted < 50% with chronic respiratory failure.) Patients with a confirmed diagnosis of COPD for more than 12 months, who were prescribed inhaled medications for follow-up or discharge management, and had a follow-up review at least 4 weeks after initiating treatment, were included. The exclusion criteria were patients who refused to participate or were unable to understand a simple questionnaire. All participants provided written informed consent, and this study was approved by the Ethics Committee of the First Affiliated Hospital of Harbin Medical University.

Questionnaire on medication adherence to inhaled therapy in COPD patients

A questionnaire on medication adherence and disease control level was customized and designed with reference to relevant literature and based on local actual conditions. The questionnaire consisted of three parts: basic information (such as demographic information of the patients and their self-perception of the disease), medication adherence (including the frequency and dosage of inhaled medication, long-term medication use, factors affecting adherence, and follow-up visits to the hospital), and disease control level (such as acute exacerbation events and reasons for hospitalization in the past year). A scoring system was applied, whereby adhering strictly to medication instructions or attending follow-up visits was assigned a score of 0, while other options were assigned scores ranging from 1 to 3. By summing these scores, patients were categorized into two groups: those with good adherence (0–6 points) and those with poor adherence (7–12 points) [6, 16, 22,23,24,25,26,27,28,29,30,31].

Survey methodology

The initial survey employed a paper-based questionnaire, utilizing a convenience sampling method. Designated researchers conducted face-to-face interviews to elucidate the questionnaire content and recorded patients’ verbal responses, which were promptly collected on-site thereafter. Considering multiple factors, including the evaluation cycle of drug efficacy, patterns of changes in patient adherence, and practical feasibility in clinical practice, a second survey was conducted at the 8-week mark. This follow-up survey was administered via telephone by the same designated researchers, during which patients once again provided their verbal responses. These responses were documented and collected in real-time by the researchers.

Statistical methods

Statistical analysis was performed using SAS 9.4, an international standard statistical programming software. Categorical data were described using frequencies and percentages, and comparisons between groups were conducted using the chi-square test. For the analysis of risk factors, binary logistic regression analysis was employed. To avoid collinearity among variables, a stepwise regression method was utilized for variable selection. A P-value < 0.05 was considered statistically significant.

Results

General information

A total of 977 patients were included in this study. The age range was from 50 to 89 years, with a mean age of 63 ± 9 years. Among them, 437 (44.8%) were females, and 540 (55.2%) were males. Furthermore, 747 (76.5%) patients had a history of smoking, while 230 (23.5%) patients had never smoked. The frequency distribution of age, occupation, education level, and family caregiving status of the surveyed patients is detailed in Table 1.

Table 1 Frequency distribution of surveyed patients’ age, occupation, educational level, and family supervision status

Treatment adherence among surveyed patients

In the initial survey, it was found that 524 (53.6%) patients reported obtaining their medications through medical prescriptions, while 305 (31.2%) patients acquired medications through non-prescription channels (such as online purchases and folk remedies), and 148 (15.2%) patients relied on recommendations from peers, relatives, or neighbors for their medication use (Fig. 1). This indicates that a significant proportion of patients obtain their medications from sources other than medical advice, and their medication regimens may not necessarily be appropriate or rational.

Fig. 1

Source of therapeutic drugs

At the 8 th week post-consultation, during the second survey, 305 patients (31.2%) demonstrated good medication adherence by strictly following the prescribed medication regimen. The remaining patients exhibited poor medication adherence, with 228 patients (23.3%) self-adjusting their medication dosages and 444 patients (45.5%) discontinuing their medication (Fig. 2). Among those who discontinued their medication, 298 patients (45.4%) did so within the first month after the consultation. The reasons for discontinuation were varied: 50.8% of patients believed they could stop the medication once their symptoms alleviated, 24.3% were concerned about adverse drug reactions or the potential for developing drug resistance with long-term use, 19.9% cited the high cost of long-term medication, and 5% mentioned inconvenience in medication administration or negative impacts on work and daily life (Fig. 3).

Fig. 2

Drug adherence

Fig. 3

Reason for discontinuation of medication

Among the patients surveyed, 20.5% adhered to the physician’s recommendation for regular follow-up visits, 21.6% attended follow-up visits intermittently after the initial consultation, and 57.9% did not seek follow-up unless there was a significant change in their condition (Fig. 4). Among those who did not attend regular follow-up visits, 34.3% cited busy work schedules and lack of time as the primary reasons, 31.5% believed that the distance from their residence to the hospital or the inconvenience of follow-up visits was a barrier, 22.5% thought that follow-up was unnecessary if their symptoms did not recur after each visit, and 11.7% mentioned financial reasons for not attending regular follow-up visits (Fig. 5).

Fig. 4

Follow up status

Fig. 5

Reasons for not being able to have regular follow-up visits

Among the patients who were able to attend regular or intermittent follow-up visits, 40.7% chose not to return to their previous hospital. Of these, 37.7% made this decision because they perceived the previous physician as lacking patience or disliked the hospital staff for other reasons, 31.7% opted for a hospital closer to their home for convenience, and 30.6% chose another physician or hospital because they believed the previous hospital had higher costs (Fig. 6).

Fig. 6

Reasons for not choosing the same hospital for treatment

In terms of treatment adherence, the analysis revealed that 400 patients (40.9%) consistently demonstrated good adherence to the prescribed treatment regimen. Conversely, a substantial proportion of 577 patients (59.1%) exhibited poor treatment adherence, highlighting a concerning trend (Fig. 7).

Fig. 7

Adherence

Disease control level in surveyed patients

The disease control level of COPD patients surveyed was evaluated utilizing the CAT score and the mMRC dyspnea scale. In the second survey, 405 patients (41.5%) had CAT scores < 10, indicative of a good quality of life, whereas 572 patients (58.5%) scored ≥ 10, suggesting a poor quality of life (Fig. 8). With respect to the mMRC dyspnea scale, 431 patients (44.1%) presented with an mMRC score of 0–1, signifying mild symptoms, while 546 patients (55.9%) had an mMRC score ≥ 2, indicating more severe symptoms (Fig. 9).

Fig. 8

The assessment of CAT dyspnea scale. The COPD Assessment Test (CAT) [32] Score Scale: An 8-item questionnaire rating system evaluating various aspects of COPD impact, with scores ranging from 0 to 10 indicating “mild impact,” 11–20 indicating “moderate impact,” 21–30 indicating “severe impact,” and 31–40 indicating “very severe impact.”

Fig. 9

The assessment of mMRC dyspnea scale. mMRC [33] Dyspnea Scale: A 5-level rating system to assess COPD patients’ dyspnea severity, ranging from mild (grade 0–1) to severe (grades ≥ 2)

Factors influencing treatment adherence in surveyed patients

Significant disparities were observed in treatment adherence among the patients surveyed, contingent upon age group, annual household income level, family supervision, and type of medical insurance (P < 0.05). Patients who were younger than 70 years of age (P = 0.03), had an annual household income exceeding 50,000 yuan (P = 0.04), received supervision from family members (P = 0.01), and possessed additional commercial medical insurance (P = 0.02) exhibited greater adherence to inhaled medication therapy. Remarkably, patients under 70 years old (OR = 5.1, CI = 1.13–23.11) and those under family supervision (OR = 3.26, CI = 1.3–8.21) demonstrated significantly higher levels of adherence (Table 2). Conversely, no significant differences in adherence to inhaled medication therapy were discerned based on gender (P = 0.66), smoking status (P = 0.29), or educational background (P = 0.59) (P > 0.05) (Table 3).

Table 2 Results of multivariate analysis

Table 3 Factors associated with good treatment adherence

Correlation analysis between disease control level and treatment adherence in patients

A statistically significant correlation was found between the disease control level and treatment adherence among the surveyed patients (P < 0.05).

Discussion

In this survey, we conducted an in-depth analysis of disease control status and quality of life among COPD patients. The results revealed that only 40.9% of the surveyed patients demonstrated good medication adherence, a proportion that is comparable or lower than those reported in medication adherence surveys of patients from other regions [34,35,36,37,38], highlighting the challenges of adherence among COPD patients in northern China. Meanwhile, 431 patients (44.1%) had an mMRC score of 0–1, indicating mild symptoms, and 405 patients (41.5%) had a CAT score below 10, suggesting a relatively good quality of life.

Among patients with poor medication adherence, a high proportion of 71.2% had a CAT score of 10 or above, and 75.9% had an mMRC score of 2 or above, indicating that these patients experienced more frequent and severe respiratory symptoms. These data highlight a clear correlation: the poorer the adherence, the more pronounced the impairment in respiratory symptom control (P < 0.05). Previous studies have also confirmed that adherence and disease severity are intertwined, with adherence playing a crucial role in optimizing treatment outcomes during the stable phase of COPD. Improving adherence can significantly enhance disease management, reduce healthcare-related costs, and improve quality of life [6, 39,40,41].

The low treatment adherence rates observed among the surveyed patients are closely linked to several underlying factors. Firstly, economic factors pose a significant barrier. A considerable proportion of patients come from economically disadvantaged families, with 90.9% reporting an annual household income below 50,000 RMB. Furthermore, 44.9% of patients have an annual income of less than 20,000 RMB. This financial constraint significantly impacts their ability to access comprehensive and sustained treatment for COPD. Secondly, geographical factors also play a pivotal role. Approximately 69.2% of the surveyed patients reside in remote areas such as towns, villages, or mountainous regions. Geographical isolation makes follow-up visits challenging, leading to patients’ reluctance to attend regular check-ups. Additionally, the interpersonal relationship between patients and physicians emerges as a critical determinant of treatment adherence. The attitude of physicians during consultations significantly influences patients’ willingness to adhere to medication regimens and attend follow-up appointments. Among those surveyed who chose not to revisit the same hospital or physician, 37.7% cited previous negative healthcare experiences, such as lack of patience from physicians or cumbersome clinic processes, as the primary reasons for their decision not to return to the initial physician for follow-up. These findings emphasize that, in addition to addressing economic and geographical barriers, there is a need to improve interpersonal relationships within healthcare services to enhance patients’ adherence to inhaled medication therapy and ultimately improve their quality of life.

Among the surveyed participants with inadequate disease control, 46.3% of those with a CAT score of 10 or higher expressed a preference to shift towards oral or intravenous medications, while 32.6% attributed their suboptimal disease management to the exclusive reliance on inhaled medications. Upon delving into the root causes of these preferences, it was revealed that 65.9% of patients lacked a comprehensive understanding of COPD medications and related knowledge. They assumed, based on their experiences with other conditions, that oral and intravenous medications represented the standard treatment modalities and, by extension, presumed that similar approaches should be applicable to COPD. This underscores a notable correlation (P < 0.05) between patients’ grasp of the disease, their awareness of the effectiveness of inhaled therapies, their appreciation of the significance of inhaled medications in disease management, and their adherence to prescribed inhalation regimens. Moreover, it is noteworthy that 69.2% of the surveyed individuals were aged 60 years and older, a cohort that typically encounters greater difficulties in accessing and comprehending disease-related information compared to their younger counterparts. Consequently, relying exclusively on patients to proactively seek out information on COPD prevention and treatment is insufficient and may not yield the desired outcomes. In light of this, it is imperative to implement educational initiatives that are specifically tailored to enhance COPD awareness. These measures could encompass a range of activities, including but not limited to: the establishment of COPD patient support groups or public WeChat accounts to facilitate communication and the dissemination of accurate COPD-related knowledge and inhaled medication guides; the organization of periodic educational seminars and awareness campaigns on COPD and inhalation therapy within hospital settings or hospital wards; and the distribution of informative COPD materials within community settings. By embracing these strategies, we can empower patients with a more thorough understanding of COPD, reinforce the correct techniques for utilizing inhalation devices, and emphasize the crucial role that adherence to prescribed inhaled medication regimens plays in managing the disease. Ultimately, these efforts are aimed at improving patients’ adherence to inhalation therapy, thereby contributing to better disease management and enhanced quality of life.

In the complex domain of COPD management, the cornerstone of effective disease control and subsequent improvement in patients’ quality of life lies in their adherence to prescribed inhalation medication regimens. As healthcare professionals, we bear the responsibility of developing and implementing comprehensive strategies that not only cater to individual patient needs but also ensure optimal adherence outcomes. Prior to initiating inhalation therapy, physicians must meticulously assess patients’ potential for adherence, with a particular focus on identifying and eliminating potential barriers among vulnerable populations, including the elderly, those experiencing economic hardships, and individuals lacking family support. This necessitates a nuanced understanding of the multifaceted factors influencing adherence, ranging from socioeconomic status to mental health. Enhancing patient education emerges as a potential effective entry point for clinicians to improve medication adherence. After establishing the prescription for stable-phase medication, physicians should design comprehensive health education programs to help patients gain a deeper understanding of the pathophysiology of COPD, the rationale behind their medication, and the severe consequences of non-adherence. This requires the integration of cutting-edge educational methods, such as multimedia presentations, interactive simulations, and personalized counseling sessions [42], to ensure that the information is both accessible and engaging. To further enhance the effectiveness of these educational programs, several practical techniques can be employed. For instance, utilizing visual aids like diagrams and videos can greatly facilitate patients’ understanding of complex medical concepts. These visuals can illustrate the structure and function of the lungs, the mechanism of action of inhalation medications, and the potential impacts of non-adherence on lung health. Moreover, incorporating interactive elements into educational sessions can promote active learning and retention. This can be achieved through question-and-answer sessions, group discussions, or role-playing activities where patients practice using their inhalation devices correctly. By actively engaging with the material, patients are more likely to retain the information and apply it in their daily lives. In addition, tailoring educational materials to patients’ literacy levels and cultural backgrounds is crucial. Using simple language, avoiding medical jargon, and providing translations when necessary can ensure that the information is accessible to all patients. Cultural sensitivity should also be considered, as patients from diverse backgrounds may have different beliefs, values, and practices that can influence their adherence to medication. Leveraging innovative communication channels and platforms is also crucial for maintaining an ongoing dialogue with patients. By utilizing digital tools such as online portals, social media accounts, and mobile applications, healthcare providers can disseminate and timely update COPD-related knowledge, remind patients of regular follow-up appointments, and tailor individualized educational materials to the unique needs of COPD patients. For example, mobile apps can be designed to provide daily medication reminders, track symptoms, and offer educational content tailored to the patient’s progress and needs. The focus on education is particularly significant because clinicians have limited ability to address issues related to patients’ family income, health insurance, and other socioeconomic factors that may impact adherence. By empowering patients with knowledge and skills through education, we can bridge this gap and promote self-management capabilities, which are essential for long-term disease control.

Furthermore, involving family members or caregivers in the educational process can enhance patients’ support systems and improve adherence. Family members can be taught how to assist patients with their medication regimen, recognize signs of exacerbations, and encourage healthy lifestyle choices. This collaborative approach can foster a sense of teamwork and shared responsibility in managing the patient’s COPD. Through regular assessment of patients’ disease status and treatment response, healthcare providers can dynamically adjust treatment plans to ensure they consistently meet individual patient needs. This ongoing evaluation allows for the identification of any adherence issues or changes in the patient’s condition, enabling timely interventions and adjustments to the treatment plan. This personalized, long-term approach to COPD management, incorporating comprehensive patient education, practical techniques, and ongoing assessment, not only aids in improving medication adherence and disease control but also has the potential to enhance patients’ overall quality of life. By empowering patients with knowledge, skills, and support, we can help them take an active role in their own care and achieve better health outcomes.

This study was conducted in northern China, a region where specific lifestyle habits and a cold climate lend a unique regional relevance to our research. Compared to other regions internationally, patient medication adherence in this area is relatively low [42]. This is potentially attributable to factors such as the Unified Rural and Urban Resident Basic Medical Insurance (URRBMI) system’s impact on the health and health inequalities of rural elderly populations, coupled with the region’s low annual per capita income [43]. It is recommended to establish a healthcare financing and welfare system that takes into account income and age, and to develop a unified public medical insurance system tailored specifically for the elderly population.

A study conducted in Yunnan, China, reported that 19.8% of COPD patients have never smoked [44]. In contrast, 23.5% of the patients surveyed in our study had no smoking history. The higher proportion of non-smoking COPD patients in our study may be linked to several factors. The study area, located in Heilongjiang Province in northeastern China, experiences long and cold winters (December to February) with an average provincial temperature of − 16.3 °C (as per the Heilongjiang Provincial Climate Bulletin (2020), available at hl.cma.gov.cn/zfxxgk/zwgk/qtxx/202101/t20210122_2638629.html). The primary heating method involves coal combustion, either through central heating or household coal heating. The particulate matter (PM10, PM2.5, etc.), sulfur dioxide, and nitrogen oxides emitted from coal burning may contribute to the increased incidence of COPD [18, 19]. Additionally, Heilongjiang Province is an agricultural region where farmers burn straw every spring and autumn, which may also release harmful substances and induce COPD. Residents in rural areas or those living in non-apartment buildings often use coal and wood for cooking, the main cooking method for this population, which may lead to chronic respiratory irritation and subsequently, the development of COPD. Other potential contributors to the occurrence of COPD include e-cigarettes, occupational hazards, air pollution, and household pollution. Therefore, our study results not only offer valuable insights into medication adherence among patients in this region, aiding local doctors in managing and treating patients, but may also provide transferable experiences for other similar regions. Furthermore, exploring the incidence of COPD and its related influencing factors in similar areas could be a promising direction for future research.

This study has several limitations. Firstly, the adherence data were collected based on self-reports from patients, which may be prone to over-reporting or under-reporting. To address this, future research should adopt objective methods for measuring adherence, such as utilizing pharmacy refill records or tracking inhaler usage, to provide a more accurate assessment of patient adherence. Secondly, the data for this study were sourced exclusively from one hospital in northern China, potentially limiting the generalizability of the results. To enhance the applicability of the findings, future studies should incorporate data from multiple regions and hospitals. Lastly, this study did not include a comprehensive comparison with global COPD adherence research, nor did it delve deeply into the adherence interventions explored in previous studies. To more effectively enhance adherence, future research should incorporate a broader range of international data to comprehensively evaluate the adherence status of COPD patients. Furthermore, while this study highlighted the influence of income, insurance, and family support on adherence, it is acknowledged that improving education and awareness alone may not fully resolve the issue of adherence. Therefore, future studies should further investigate additional intervention measures and conduct long-term follow-up studies to assess the impact of these interventions on patient adherence.

The complex interplay among inhalation medication adherence, disease control levels, and patient quality of life in COPD necessitates a multifaceted and proactive approach by healthcare providers. By enhancing patient education, leveraging innovative communication channels, maintaining accurate disease monitoring, and educating family members to facilitate home-based supervisory support for patients, we aspire to achieve optimal outcomes, including improved disease control, reduced frequency of acute exacerbations, and enhanced quality of life.