Assessing Treatment Adherence in COPD

Strategies currently used to monitor patients’ adherence to chronic obstructive pulmonary disease treatment, and thoughts on incorporating smart inhalers into management.

Neil Minkoff, MD: Dr Mahler, we’ve talked about the guidelines and the recommendations. Part of that is making sure the patients are staying on therapy and being adherent. You’ve talked a lot about patient engagement. What are some of the mechanisms you try to use with your patients to support adherence? What do you say to some of us who might not be skeptical but say, “Isn’t breathing better enough of an incentive?”

Donald A. Mahler, MD: First, let’s clarify adherence. Adherence can be simply defined as the patient taking the prescribed medication in the appropriate manner. That’s a very simple concept, like having a pill and taking it for my high blood pressure or my high cholesterol level. It’s easy to do, but there’s no immediate outcome associated with it. Adherence is clearly a challenge, as has been mentioned. It can be difficult to evaluate.

I’d like to point out 1 study published in the American Journal of Respiratory Critical Care Medicine. It was a prospective observational study in Ireland in which patients were educated about inhaler use when they were hospitalized for either an exacerbation or an alternative reason. They found that adherence to a dry-powder inhaler was only 23%, despite the efforts and education. It’s clearly a challenge. It’s difficult sometimes to evaluate. As you suggested, if a patient uses a medicine and it helps him or her breathe easier, that’s an extremely positive reinforcement. From my perspective, it clearly enhances the possibility of good adherence.

If the patient has a high co-pay, then they may try to stretch out the medications and maybe use it once a day rather than twice a day. They may use it every other day to make it last longer. The simple thing is to ask the patient, “Are you taking the medication as prescribed?” Hopefully, they will answer honestly. Obviously, refills are another way to evaluate it. If someone isn’t calling in for a refill after a year and a half and you prescribed a year’s supply of refills, we can assume either they’re on a different medication that you’re not aware of or they’re not taking the medication.

Part of your question was about how we improve adherence. I’m able to provide samples in my practice, so that’s 1 of the things I would do. If I can give a patient a sample of an inhaler and say, “Try this for a couple of weeks,” and it works for them—particularly if it helps them breathe better, they’re more likely to say, “I’m going to prepay whatever my co-pay is in order to use this because I already know it helps.” Pharmaceutical companies provide vouchers, which also help with reducing the cost. As Dr Lopes implied, coverage is important, but there are a lot of patients who have limited income. It’s a big portion of their disposable resources. We have to be cognizant of that.

The last but most important point is we need to educate our patients why this medicine is being prescribed. Is it being prescribed to help them breathe easier? That is usually relatively easier to assess. If we’re prescribing it to reduce the risk of future exacerbations, that means they have to take it at least 6 to 12 months to potentially see a benefit. There’s no immediate feedback that way.

Finally, as Michael mentioned, we have smart inhalers. We have sensors that can be part of the inhaler or added to the inhaler, which can tell us when they’re using it, what time of the day, and what their inspiratory flow is. That can be potentially useful information. We don’t have a lot of studies to show the benefits of these smart inhalers, but that’s certainly something that is going to be utilized more in the future.

Neil Minkoff, MD: Mr Hess, are you using any of those?

Michael Hess, MPH, RRT, RPFT: Not so much in our practice. It’s just the way things shake out with our formularies and things like that. We don’t have a lot of people who are on those devices. However, I have seen on a national scale that they can be tremendously effective. I have experimented with smart inhalers a little. The technology is very sound. They provide a wealth of information and reminders. There are devices that give you prompts to your smart device that say, “It’s time to take your medication.” That’s a big issue with a lot of folks. It’s been mentioned a couple of times, but we have people with cognitive impairments who simply forget to take their twice-a-day medications. One of the things I say is that everybody is really good at taking their medications in the morning, myself included, but sometimes we forget that afternoon dose. Life happens, so it’s good to have reminders. It’s good to have tracking involved. Are you in a certain place when you’re using your short-acting bronchodilator frequently? Is it a certain time of day? Once we have enough longitudinal data, is it a certain time of year? Do we need to look at improved allergy control or things like that? As we move forward, these devices are going to be an integral part of care at every level.

Neil Minkoff, MD: If you’re not using the smart devices, I’m assuming it’s something as basic as asking the patient to demonstrate their technique in front of you?

Michael Hess, MPH, RRT, RPFT: Basically, yes. I do the teach-back because I learned early on in doing the outpatient stuff, as Dr Mahler alluded to, that not everybody is always honest about how they’re taking their medications. I have found that if you ask somebody if they’re taking them, oftentimes they’ll say yes regardless of whether they are. But if you ask them how they are taking them, they’ll be honest about that, and that’s when you find out if they are doing the appropriate number of puffs or using it the appropriate number of times per day.

Then you start getting into adherence questions and technique questions—that sort of thing. It also, in my opinion, helps build a little trust. If you call somebody out on inaccurate reporting, they’re going to feel guilty about it, and they may not be as forthcoming in the future. But if you ask them how they’re using their medications and you find an error, then you can take that opportunity to say, “Perhaps I made a mistake in teaching you.” Then you can do the reinstruction and you can build that trust. People are far more likely to adhere to the plan in that case.

Maria Lopes, MD, MS: There’s the aspect of efficiency as well. We are delivering more consistent care and capturing important insights in terms of patient engagement and the potential gaps that may exist, but without this understanding, it would have gone unnoticed. That has potential consequences in terms of hospitalizations, ED [emergency department] visits, and exacerbations that hopefully can be prevented. We are on the brink of innovative digital solutions providing more insight and doing more in terms of patient engagement. If it’s embedded into the care-delivery model, it can enhance patient experience as well as the efficiency with which we deliver care.

This activity is supported by an educational grant from Boehringer Ingelheim.

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