COPD insider

Improving adherence to treatment:

The cornerstone of COPD treatment success

 

While we would all agree that adherence to treatment is key, the causes

of nonadherence may surprise you. Learn more about what can go wrong

and how you can make it right.

Keeping the

balance of care

 

You devote countless resources to getting patients healthy following an exacerbation. And you devote countless more to keeping them healthy at home—and not coming back for more critical care. This is nothing short of a high wire act. 

 

But one factor can make all your efforts futile. It can make patient care fall to pieces and turn your situation from optimistic to unsustainable. This factor is all too familiar—it’s lack of adherence to treatment. 

 

You may feel that patient adherence to treatment is somewhat out of your hands. This is true, but only to a point. You may be very surprised at some of the underlying causes of non-adherence, as well as how much power you have to control them. 

 

Let’s dive deeper into how you can better balance care long-term.

Education goes both ways

 

Setting patients up for adherence to treatment starts with you. You are on the frontlines of educating them about their disease and devices. But think about this—education needs to be a two-way street.

 

Beyond educating patients, they need to educate you on their treatment and lifestyle goals. This uniquely positions you to frame a personalized and patient-preferred approach to care. It not only strengthens the patient-physician relationship, but also helps patients understand their role in successful treatment. 

 

While physicians have the best intentions at heart, this is a perspective on treatment that most underrecognize. But positive change is as simple as starting the conversation.

Contributors

Becky Anderson

Becky Anderson, RRT

Manager,

Respiratory Care Services,

Sanford Medical Center

Brian Carlin

Brian Carlin, MD, FCCP, FAARC

Critical Care Staff Physician

Altoona Regional Health System

Jill Ohar

Jill Ohar, MD, FCCP

Professor of Internal Medicine, Pulmonary, Critical Care, Allergy, and Immunological Diseases

Wake Forest University School of Medicine

Director of Clinical Operations

Wake Forest University Baptist Medical Center

"Lack of adherence are mostly our fault because the patient is not educated to the level that they need to be and can respond to."

-Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Hospital

On the need to uncover a patient's story

 

-Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Hospital

On the need to uncover a patient's story video

Start the conversation

 

Help find out what your patients want most out of their COPD treatment with these conversation starters:

Before your COPD diagnosis, what activities did you like to participate in that you would enjoy doing again?”

What does successful treatment mean to you?”

In regards to treatment, what short- and long-term goals would you like to achieve?”

The right device makes a world of difference

Picture this. A patient sits in room number 4 as their physician demonstrates the steps required to use their newly prescribed inhaler. The physician says,

 

“So I’m going to write you a prescription for a metered-dose inhaler. To use it correctly you need to take a deep breath out, then hold it up to your mouth and inhale as you simultaneously press down on the top. Give it a try.”

 

The patient tries to use the device and struggles with the hand-breath coordination needed to help their COPD. The physician says,

 

“I can see the hand-breath coordination is not allowing you to get the medication you need. Let’s go with an aerosol delivery device that requires less steps. This will help you get the proper amount of daily medication needed to help your symptoms.”

 

For patients to adhere to therapy, they can’t just have an effective device. They need to have the right one—one that considers their abilities, fits easily into their life, and addresses their medical need. The inhaler discussed above may be ideal for some patients. But for others, it may be way too complicated. This can lead to confusion, then lack of use. And you know all too well what comes next.

Over 50% of patients struggle to use metered-dose inhalers properly

The most common reason for

non-adherence in patients >65 years or older is

underuse or improper

use of devices1

What matters most in a device?

 

The top 3 device characteristics to keep in mind trying to improve adherence to treatment are1:

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Frequency of administration

 

The fewer administrations per day, the higher the chance of consistent adherence to therapy

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Ease of use

 

The easier to use, the less risk of incorrect administration or treatment avoidance

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Rapid onset of action

 

The faster patients feel the effect, the more they may be inclined to adhere to treatment

The numbers don’t lie

 

During a 12-month study period, the percentage of patient’s adherent to therapy significantly improved as the number of administrations per day decreases.1,2

Bar graph
*Study design: A total of 55,076 patients met the criteria for inclusion in the study. The most frequent daily dosing frequency class of the initial drug taken as of the index date was BID, which accounted for 45.4% of the population, followed by QID (39.7%), TID (8.3%), and QD (6.7%).

Here’s a tip—think beyond familiar “prescribed” devices. Take fitness tracking devices for example. These devices may help patients by potentially giving them immediate, usable performance feedback. This may give patients a real-time picture of their activity and may help motivate them to take charge of their treatment.

On the importance of tracking activity

 

-Brian Carlin, MD, FCCP, FAARC

Critical Care Staff Physician

Altoona Regional Health System

On the importance of tracking activity video

Treating psychological comorbidities is critical

Patients with COPD often have other conditions, beyond those respiratory. These may severely interfere with adherence to therapy.3

 

Consider this: depression affects up to 42% of patients with COPD.And, for patients who are dependent on supplemental oxygen this number jumps to 60%.3

“Readmission and non-adherence is astronomically higher among patients who have depression.” 

-Jill Ohar, MD, FCCP

Professor of Internal Medicine,

Pulmonary, Critical Care, Allergy, and Immunological Diseases

Wake Forest University School of Medicine

Director of Clinical Operations

Wake Forest University Baptist Medical Center

On the need to identify comorbidities

 

-Jill Ohar, MD, FCCP

Professor of Internal Medicine,

Pulmonary, Critical Care, Allergy, and Immunological Diseases

Wake Forest University School of Medicine

Director of Clinical Operations

Wake Forest University Baptist Medical Center

On the need to identify comorbidities video

So how can you help improve adherence to treatment in patients with these psychological and physical barriers?

 

Patients with psychological comorbidities need more than the standard course of treatment. A good place to start is a pulmonary rehabilitation program. But, not just any program—one that is specifically designed. Multidisciplinary pulmonary rehabilitation programs have been shown to decrease anxiety and depression scores in patients with COPD.3

What to look for in a multidisciplinary pulmonary rehabilitation program

 

Look for these 3 aspects when considering pulmonary rehabilitation for your patients with COPD and a psychological comorbidity:3

Numeral 1

Psychocial support3

 

Patients may be able to uncover the underlying cause of their psychological comorbidity—potentially helping them get back on track with adherence to treatment

Numeral 2

Disease state and comorbidity education3

 

Patients may gain a better understanding of both COPD and how their other condition is affecting their outcomes to therapy

Numeral 3

Exercise training3

 

Patients can stabilize or reverse the functional and structural damage COPD may have caused

Improving adherence to treatment starts with you

 

With today’s stringent reimbursement and unforgiving penalties, optimizing adherence to treatment can no longer just be “Goodbye and good luck.” When you engage with your patients closer on the front end, you’ll likely be readmitting them much less on the back.

 

Educate them. Have them educate you. Choose the right device thoughtfully. Account for their underlying conditions. And watch adherence to treatment happen.

“Improving adherence to treatment is not
a one and a done, it’s along the continuum of their lifetime.”

-Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Hospital

-Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Hospital

Sources: 1. Sanduzzi A, Balbo P, et al. COPD: adherence to therapy. Multidisciplinary Respiratory Medicine Web site. https://mrmjournal.biomedcentral.com/articles/10.1186/2049-6958-9-60 Accessed December 21, 2016. 2. Toy E, et al. Treatment of COPD: Relationships between daily dosing frequency, adherence, resource use, and costs. Respiratory Medicine. 2011;105: 435-441. 3.  Franssen F, Rochester C. Comorbidities in patients with COPD and pulmonary rehabilitation: do they matter? European Respiratory Review Web site. http://err.ersjournals.com/content/23/131/131 Accessed January 13, 2017.
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