Adherence to treatment, including inhaled therapies, is low in people with cystic fibrosis (CF). Although psychological interventions for improving adherence to inhaled therapies in people with CF have been developed, no previous published systematic review has evaluated the evidence for efficacy of these interventions.The primary objective of the review was to assess the efficacy of psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis (CF). The secondary objective was to establish the most effective components, or behaviour change techniques (BCTs), used in these interventions.We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched databases (PubMed; PsycINFO; EBSCO; Scopus; OpenGrey), trials registries (World Health Organization International Clinical Trials Registry Platform; US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov), and the reference lists of relevant articles and reviews, with no restrictions on language, year or publication status. Date of search: 7 August 2022.We included randomised controlled trials (RCTs) comparing different types of psychological interventions for improving adherence to inhaled therapies in people with CF of any age, or comparing psychological interventions with usual care. We included quasi-RCTs if we could reasonably assume that the baseline characteristics were similar in both groups.Two review authors independently assessed trial eligibility and completed data extraction, risk of bias assessments, and BCT coding (using the BCT Taxonomy v1) for all included trials. We resolved any discrepancies by discussion, or by consultation with a third review author as necessary. We assessed the certainty of the evidence using GRADE.We included 10 trials (1642 participants) in the review (children and adolescents in four trials; adults in five trials; and children and adults in one trial). Nine trials compared a psychological intervention with usual care; we could combine data from some of these in a number of quantitative analyses. One trial compared a psychological intervention with an active comparator (education plus problem-solving (EPS)). We identified five ongoing trials. Psychological interventions were generally multi-component and complex, containing an average of 9.6 BCTs (range 1 to 28). The two most commonly used BCTs included 'problem-solving' and 'instruction on how to perform the behaviour'. Interventions varied in their type, content and mode of delivery. They included a problem-solving intervention; a paper-based self-management workbook; a telehealth intervention; a group training programme; a digital intervention comprising medication reminders and lung function self-monitoring; a life-coaching intervention; a motivational interviewing (MI) intervention; a brief MI intervention (behaviour change counselling); and a digital intervention combined with behaviour change sessions. Intervention duration ranged from 10 weeks to 12 months. Assessment time points ranged from six to eight weeks up to 23 months. Psychological interventions compared with usual care We report data here for the 'over six months and up to 12 months' time point. We found that psychological interventions probably improve adherence to inhaled therapies (primary outcome) in people with CF compared with usual care (mean difference (MD) 9.5, 95% confidence interval (CI) 8.60 to 10.40; 1 study, 588 participants; moderate-certainty evidence). There was no evidence of a difference between groups in our second primary outcome, treatment-related adverse events: anxiety (MD 0.30, 95% CI -0.40 to 1.00; 1 study, 535 participants), or depression (MD -0.10, 95% CI -0.80 to 0.60; 1 study, 534 participants), although this was low-certainty evidence. For our secondary outcomes, there was no evidence of a difference between groups in terms of lung function (forced expiratory volume in one second (FEV1) % predicted MD 1.40, 95% CI -0.20 to 3.00; 1 study, 556 participants; moderate-certainty evidence); number of pulmonary exacerbations (adjusted rate ratio 0.96, 95% CI 0.83 to 1.11; 1 study, 607 participants; moderate-certainty evidence); or respiratory symptoms (MD 0.70, 95% CI -2.40 to 3.80; 1 study, 534 participants; low-certainty evidence). However, psychological interventions may improve treatment burden (MD 3.90, 95% CI 1.20 to 6.60; 1 study, 539 participants; low-certainty evidence). The overall certainty of the evidence ranged from low to moderate across these outcomes. Reasons for downgrading included indirectness (current evidence included adults only whereas our review question was broader and focused on people of any age) and lack of blinding of outcome assessors. Psychological interventions compared with an active comparator For this comparison the overall certainty of evidence was very low, based on one trial (n = 128) comparing an MI intervention to EPS for 12 months. We are uncertain whether an MI intervention, compared with EPS, improves adherence to inhaled therapies, lung function, or quality of life in people with CF, or whether there is an effect on pulmonary exacerbations. The included trial for this comparison did not report on treatment-related adverse events (anxiety and depression). We downgraded all reported outcomes due to small participant numbers, indirectness (trials included only adults), and unclear risk of bias (e.g. selection and attrition bias).Due to the limited quantity of trials included in this review, as well as the clinical and methodological heterogeneity, it was not possible to identify an overall intervention effect using meta-analysis. Some moderate-certainty evidence suggests that psychological interventions (compared with usual care) probably improve adherence to inhaled therapies in people with CF, without increasing treatment-related adverse events, anxiety and depression (low-certainty evidence). In future review updates (with ongoing trial results included), we hope to be able to establish the most effective BCTs (or 'active ingredients') of interventions for improving adherence to inhaled therapies in people with CF. Wherever possible, investigators should make use of the most objective measures of adherence available (e.g. data-logging nebulisers) to accurately determine intervention effects. Outcome reporting needs to be improved to enable combining or separation of measures as appropriate. Likewise, trial reporting needs to include details of intervention content (e.g. BCTs used); duration; intensity; and fidelity. Large trials with a longer follow-up period (e.g. 12 months) are needed in children with CF. Additionally, more research is needed to determine how to support adherence in 'under-served' CF populations. 

/pdf/psychological-interventions-for-improving-adherence-to-25lr7fkl.pdf

Psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis

P399 Using a digital learning health system to reduce medicines waste in cystic fibrosis – the Easy Medicines for Burden Reduction And Care Enhancement (EMBRACE) study

Objectives To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability.



Setting Two UK cystic fibrosis (CF) units.



Participants Fourteen adult PWCF; three professionals delivering adherence support (‘interventionists’); five multi-disciplinary CF team members.



Interventions Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month).



Primary and secondary measures Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics.



Results Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%–92%, respectively, indicating that interventionists needed to focus more on intervention ‘active ingredients’ during sessions.



Conclusions The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention.



Trial registration number ISRCTN13076797; Results.

https://bmjopen.bmj.com/content/bmjopen/10/10/e039089.full.pdf

Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation.

Objectives
This is a protocol for a Cochrane Review (intervention). The objectives are as follows:
The primary objective of the review is to assess the eBicacy of psychological interventions for improving adherence to inhaled therapies
in people with cystic fibrosis (CF). A secondary objective is to establish the most eBective components, or behaviour change techniques
(BCTs), of interventions for improving adherence to inhaled therapies in people with CF, using the BCT Taxonomy version 1 (Michie 2013).

/pdf/psychological-interventions-for-improving-adherence-to-4lynzprjct.pdf

http://www.cysticfibrosisjournal.com/article/S1569199322006312/pdf

Corrigendum to "Using a learning health system to understand the mismatch between medicines supply and actual medicines use among adults with cystic fibrosis" [J Cyst Fibros (2022), 21/2, 323-331].

P337 Easy Medicines for Burden Reduction and Care Enhancement: using real time adherence data to optimise inhaled therapies in adults with cystic fibrosis. The UK National EMBRACE programme

<h3>Introduction</h3> CFHealthHub is a digital platform and behaviour change programme for people with cystic fibrosis (CF). We present part of the CFHealthHub Easy Medicines for Burden Reduction and Care Enhancement (EMBRACE) study, which was to understand participant experiences of obtaining repeat supplies of nebulised medicines. <h3>Methods</h3> 1191 people who had consented to the CFHealthHub learning health system were emailed an online Qualtrics® survey containing both quantitative and qualitative questions. One reminder was sent after 2 weeks. Completed surveys were analysed using MS Excel® and themes were identified. <h3>Results</h3> 203 (17%) surveys were completed (28 were &lt;50% completed and excluded). 175 (14.7%) surveys were analysed. Participants were from 14 different adult centres, aged 16–75 y (mean 39.4 y) and 57.7% were female. Most people (58%) obtained medicines from a combination of routes (e.g., GP and/or hospital). 55% participants received 1+ nebulised medicines prescriptions from the GP. The hospital service differed by centre: dispensed in the hospital pharmacy then collected (49%)/delivered (83%); or a hospital prescription dispensed at a community pharmacy (39%). One third of people only received their nebulised medicines from homecare. Table 1 includes a summary of themes. <h3>Conclusion</h3> Many people use more than one route to obtain their medicines, creating a need to manage ordering in different ways depending on the drug. There was a desire for more automation and online or app based ordering, and for all medication to be available from the same place. There is room for improvement in medication ordering systems. CFHealthHub real-time data capture can be used to personalise repeat supplies. 

P64 Using the CFHealthHub learning health system to understand the experiences of adults with cystic fibrosis of obtaining repeat supplies of nebulised medicines: results of a national survey

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Corrigendum to "Using a learning health system to understand the mismatch between medicines supply and actual medicines use among adults with cystic fibrosis" [J Cyst Fibros (2022), 21/2, 323-331].

P337 Easy Medicines for Burden Reduction and Care Enhancement: using real time adherence data to optimise inhaled therapies in adults with cystic fibrosis. The UK National EMBRACE programme

P64 Using the CFHealthHub learning health system to understand the experiences of adults with cystic fibrosis of obtaining repeat supplies of nebulised medicines: results of a national survey