Three strategies to overcome improper inhaler use, the biggest hidden danger in COPD
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As the saying goes, “knowing is half the battle.”
Prescribing the right treatment for your COPD patients is critical, but what if your patients don’t grasp how to use the respiratory inhalers they’re given? It’s a frightening thought, and even more frightening when you learn how astonishingly high the rate of device misuse is. Studies have found that when it comes to inhalers, improper use is as high as 88%.1,2
Studies have found that when it comes to inhalers, improper use is as high as:
Insider intel: the prevalence of inhaler misuse1
Researchers conducted a cross-sectional observational study of 298 COPD patients who used at least one inhaler device each. They evaluated five inhaler types and found that the rates of improper usage were overwhelming for all of them:
Type of inhaler / Rate of misuse
MDI
Diskus®
Turbuhaler®
Respimat®
Breezhaler®
These staggering statistics indicate that inhaler misuse is a serious threat to effective COPD treatment, and it’s clear that to reduce COPD readmissions, patients need to be better trained on how to use their devices.
“Any time you prescribe an inhaler, there should be a prompt that says, ‘Has this patient been educated?’” suggests Dr. Brad Drummond, a clinical associate professor at the University of North Carolina School of Medicine. “And if not, we need to address that.”
Of course, knowing there’s a need for better inhaler education is just the first step. Finding the best way to provide that knowledge is the real challenge. Below are three strategies to help minimize inhaler misuse among your COPD patients.
Contributors
M. Bradley Drummond, MD, MHS
Clinical Associate Professor
University of North Carolina School of Medicine’s Division of Pulmonary Diseases and Critical Care Medicine
Amy Shaheen, MD MSc
Medicine Professor, Division of General Medicine and Clinical Epidemiology, UNC Director of Population Health Services, University of North Carolina School of Medicine
Garry Kauffman, MPA, RRT, FAARC, FACHE
RT, Owner Kauffman Consulting, LLC
Bobbie V. Kumar, MD, MBA, FAAFP
Medical Director, Swedish Edmonds Urgent Care Director, Complex Care Management for Vituity
These staggering statistics indicate that inhaler misuse is a serious threat to effective COPD treatment, and it’s clear that to reduce COPD readmissions, patients need to be better trained on how to use their devices.
“Any time you prescribe an inhaler, there should be a prompt that says, ‘Has this patient been educated?’” suggests Dr. Brad Drummond, a clinical associate professor at the University of North Carolina School of Medicine. “And if not, we need to address that.”
Of course, knowing there’s a need for better inhaler education is just the first step. Finding the best way to provide that knowledge is the real challenge. Below are three strategies to help minimize inhaler misuse among your COPD patients.
Properly train your trainers
The problem isn’t that patients are simply incapable. Rather, they’re often sent home without the clear training and directions they need. The onus, says Dr. Amy Shaheen, UNC’s Director of Population Health Services, is on providers to properly educate and train clinicians – to set them up for success when the time comes to train patients. “One thing that we've really struggled with is training the trainers,” Shaheen says. “When you're training hundreds and hundreds of trainers for thousands and thousands of patients – we have 35,000 COPD patients in our system – it's a really tricky thing to do well.” Shaheen recommends following these steps to ensure COPD clinicians are adequately prepared:
Establish designated trainers for each type of inhaler
The wide variety of available inhalers is a complicating factor, says Shaheen: “While there’s a lot of novelty and invention, the plethora has actually made it incredibly confusing for patients and for providers. They're really hard to work. I think we need to say only certain people are allowed to teach this particular device, because they’re so tricky. Everything else has to be shunted to the special trainer in the clinic, because it's too complicated for people to learn all of those devices. And if you're a patient and you have [numerous types of inhalers], it’s just a disaster. As providers, we need to be more cognizant of that.”
Ensure availability of demo inhalers
Practice makes perfect, and a determined hands-on approach can help both providers and patients become experts. The tough part is getting demo versions of the inhalers. Shaheen suggests proactively working with pharmaceutical companies to make sure they’re available. Ideally, providers and practices won’t have to search for them or buy them online, she adds.
Conduct regular quality assurance checks
Once your practice has designated specific employees to be responsible for training on specific inhalers, you should conduct regular checks to ensure the trainers are still up to speed on how to properly use them. “We actually have a little checklist, and we do an annual quality assurance to make sure that the trainers actually know how [to operate them],” Shaheen says.
Aim for multiple teaching encounters
Just as you should check up on clinicians to make sure they’re continuing to use proper technique when training patients, it’s crucial to regularly follow up with patients, too. “Respiratory therapists should have multiple encounters with patients,” Drummond says. “If you look at the most successful inpatient programs, they involve a respiratory therapist, because they have teachable moments multiple times during the patient's hospitalization. I think that's really the place to initiate that training and then [do] a delayed teach-back in the clinic at that 10- to 14 day-encounter.”
Insider intel: the consequences of inhaler misuse
A real-practice study3 compared a hypothetical cohort of 100 COPD patients making at least one critical inhaler error with 100 COPD patients with no inhaler errors. The study found that the errors resulted in a yearly excess of:
11.5
hospitalizations
13
emergency room visits
19.5
antimicrobial courses
47
corticosteroid courses
“This evaluation highlights that misuse of inhaler devices, due to inadequate training or nonconsented switch of inhaled medications, is associated with a decrease in disease control and an increase in health care resource consumption and costs,” the authors of the study concluded.
Take advantage of technology
In a perfect world, every practice would have a full-time respiratory therapist who could properly demonstrate inhaler use and reinforce that education at follow-up appointments. One alternative in the absence of such an expert is to teach patients virtually. “There are a lot of resources where you can at least do inhaler education videos, and make those easy for people to find in the workflow,” says Drummond. “When you don't have the opportunity to have a certified trainer, you can at least show the patient in a standardized way how the inhaler is supposed to be used.”
Insider case study:
decentralizing resources to combat inhaler misuse
Dr. Brad Drummond wanted to find a way to decentralize his clinic’s COPD resources to make them available to a larger scope of COPD patients.
The problem:
COPD patients at PCPs don’t have access to specialized resources
“Most COPD patients in our state and most COPD patients in our healthcare plan aren't seen in our COPD clinic,” Drummond explains. “They're cared for by primary care providers outside of our system or inside of the system. So one of our efforts has been to think about how can we decentralize resources, because it's nice if you have everything in this little clustered ivory tower, but that only helps a very small portion of the population.”
The solution:
a website to educate a wider swath of patients and providers
Drummond and his team built a site that features helpful tools, like inhaler identification cards, device education videos, a directory of pulmonary rehab centers in the state, and links to helpful resources. “If you're in with a patient and you're starting them on a certain device, you can, with basically three clicks, get to an educational video that's developed for patient level training,” Drummond says.
The result:
more COPD patients are accessing pivotal information
The site receives about 100 hits a month – “which doesn't sound like a lot, but it isn't something that we branded or broadcast anywhere, that’s just sort of grassroots use,” Drummond explains, adding that the average user is on the website for 4 to 5 minutes at a time, “which tells us that they're actually using the website.”.
Respiratory therapist Garry Kauffman is working on a virtual tool that takes things one step further than pre-recorded videos. He’s toying with a system that would allow clinicians to regularly touch base with patients on live video calls to ensure that they’re using their inhalers properly. “We're just missing [the misuse] because we're not investing that time,” Kauffman says. Dr. Bobbie Kumar is working on a similar virtual solution, inspired by Amazon’s Alexa: an app that would connect patients with an expert when they have questions or need assistance. “I think that it would be entirely useful to have something like that, where they could do a Skype or a FaceTime or a video call to provide that education and ensure that the questions are being answered,” Kumar says. “[We could] also take that information back to the primary care and back to the care team to let them know that this question was asked, this was what was done, and this is how we should go forward.”
Virtual check-ins via video calls allow:
Patience and persistence pay off
Even the most well-intentioned initial education session can fall short, so the key is to continue chipping away until patients achieve device mastery. “We can't expect a patient who's got chronic illness, who's getting a new inhaler for the first time, and probably with multiple delivery systems, to get it all in one fell swoop,” Drummond says. Whether it’s increasing emphasis on clinician training, implementing routine education follow-ups and check-ins, or taking advantage of new teaching technology, tackling inhaler misuse isn’t as daunting as it may seem, and making it a priority will reduce the biggest hidden danger to effective COPD treatment.
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Further reading
COPD insider
References 1. Liang CY, Chen YJ, Sheu SM, Tsai CF, Chen W. Misuse of inhalers among COPD patients in a community hospital in Taiwan. Int J COPD. 2018:13:1309-1316. 2. Khassawneh BY, Al-Ali MK, Alzoubi KH, et al. Handling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalers. Respir Care 2008;53(3):324-328. 3. Roggeri A, Micheletto C, Roggeri DP. Inhalation errors due to device switch in patients with chronic obstructive pulmonary disease and asthma: critical health and economic issues. Int J COPD 2016:11(1): 597—602
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