COPD: An Individualized Approach to Medication and Delivery - Episode 10
Peter Salgo, MD: Whether it’s a hand-held device or it’s a nebulizer, somebody’s got to teach the patient how to use it. How comfortable are physicians in teaching patients—going over technique?
Barbara P. Yawn, MD, MSc, FAAFP: Well, primary care physicians are not. We’re not usually the ones that do it. In the study that I think a lot of people quote—about looking whether it was physicians, residents, nurses, or respiratory therapists—physicians were the worst at even knowing how to use all of these different devices, let alone teaching about them. Most of us have nurses who do this. The problem is, they don’t have enough time. There is, in theory, reimbursement for this. It’s very minimal, and it takes a lot of extra paperwork. So, it just doesn’t happen. We really have to make people feel accountable for this. This is just as critical as diagnosing and prescribing the right medicine.
Byron Thomashow, MD: The foundation has an app, which is free in the app stores. We’re presently in the process of adding things to that app—anxiety scores, depression scores, exacerbations. Most importantly, we’re going to be adding the ability to look at the different devices. You can sit there, take out your iPhone, and show the patient how to use it. That hopefully will become available, later this year.
Peter Salgo, MD: Does the patient have access to the app, too?
Byron Thomashow, MD: We will figure out a way to do that.
Peter Salgo, MD: So, the patient can take out the patient’s iPhone and compare it.
James F. Donohue, MD: That’s exactly right.
Antonio Anzueto, MD: I use a lot of YouTube. When I see the patient, I show them the placebo device and say, “Go to this place. Put this in YouTube. Just watch that.” I have many patients that do that, and they say, “Oh, yes, I watched that.”
Barbara P. Yawn, MD, MSc, FAAFP: I think it’s very, very helpful. But if you do not watch the patient do it, you cannot be sure that they understood and incorporated what they saw. And one of the things that we all have to do is medication reconciliation. That’s basically required, at every single visit. So, if you’re going to do medication reconciliation and they’re on an inhaler, do the observation. And people say, “Whoa, wait a minute. They’re going to take an extra dose of medicine.” Who cares? There is no COPD medicine that demonstrates that taking 1 extra dose a day is going to do anything bad. So, we really need that nurse to observe the technique when they do the medication reconciliation.
Byron Thomashow, MD: I agree, completely, with what Barbara just said. But it comes back to your conversation from the beginning, Peter, about the comorbidities. Anyone who prescribes 10, to 12, to 15 medicines for a patient, who thinks that they’re going to fill 10 to 15 medications, is fooling themselves. Even if you’ve got a drug plan with a co-pay, if you start multiplying 10 to 15 times the co-pay, it’s a lot of money. And it’s particularly a problem in the COPD world, because people have the option of cutting back on their activity level. They don’t feel that they need the medicines. It’s the wrong approach, and is one that we need to fix. But there isn’t a simple answer.
Peter Salgo, MD: That’s the kind of self-normalizing that we were talking about before. We all know about this study that I was taught, years ago—they tried giving medical students, as a test, 1 dose of a placebo, once a day, for a year. They said, “Just do this. Take this placebo, once a day.” And at the end of the year, they collected the untaken pills. It was about 30%. For 1 pill, once a day, this is crazy.
Barbara P. Yawn, MD, MSc, FAAFP: And in COPD, it’s, unfortunately, exactly the opposite. It’s about 30% adherence, 70% you would get back.
Peter Salgo, MD: I’m sure it goes down as you multiply the number of pills?
Barbara P. Yawn, MD, MSc, FAAFP: Right, because of the cost and all kinds of things.
James F. Donohue, MD: We do have some advantages with new technology. For example, we now have 3 drugs in 1 inhaler. The first one is on the market, and 2 more, that I’ve been involved with, are coming. It gives you the LAMA [long-acting muscarinic antagonist], the LABA [long-acting beta-agonist], and the inhaled steroid, either once or twice a day, depending on which product you choose. That’s very nice. I think that cuts down on a lot. The costs have been in the ballpark of the duals. Then, you also have a product line. For example, one company uses the same type of device for all products. That also could be a help.
Barbara P. Yawn, MD, MSc, FAAFP: It would be a huge help, wouldn’t it? I mean, you’ve got a DPI [dry powder inhaler], a metered-dose inhaler (MDI), a soft mist, and you do them all in different ways. How can you keep track of it?
Peter Salgo, MD: That’s the razor blade business model, right? You give them the razor and sell them the blades. You lock them into a product line.
James F. Donohue, MD: That’s right.
Peter Salgo, MD: And in this case, if I hear you correctly, that’s not necessarily a bad thing?
Barbara P. Yawn, MD, MSc, FAAFP: Well, it certainly shouldn’t be, if they have the full line. Unfortunately, they don’t, yet, have the full line.
Peter Salgo, MD: If you’re going to teach somebody to use a device, what would you consider to be an adequate length of time to teach somebody to use anything? Anybody have an idea?
Barbara P. Yawn, MD, MSc, FAAFP: Well, for somebody who has COPD, it’s going to be at least, probably, 10 to 15 minutes, the first time.
Peter Salgo, MD: There goes your 7-minute patient encounter.
Barbara P. Yawn, MD, MSc, FAAFP: Oh, it’s totally gone. If I don’t do it, and the colleague that I work with does, she or he is gone for 10 to 12 minutes. Who’s going to put my next patient in? Who’s going to do the medication reconciliation? There aren’t enough bodies in there.
Antonio Anzueto, MD: So, we need to maximize resources. Patients will come, for example, to the pulmonary function lab to get spirometry. That’s a huge opportunity. They’re waiting, between bronchodilators. So, “How do you use your inhaler?” “Let’s look into that.” “I’m having a problem with this.” The medications are effective, if the patient takes them and takes them correctly. If they don’t do that, they’re not going to be effective.
Peter Salgo, MD: How common is it, with everything that’s going on, where you get a patient into your office who is using the medications incorrectly?
Antonio Anzueto, MD: 90%.
Peter Salgo, MD: 90%?
James F. Donohue, MD: It’s a lot. I actually did a study, which we published a number of years ago, where we used videos to try to answer your question. You could actually be successful in teaching a patient about an MDI like a Diskus or Ellipta. There’s only 1 step with Ellipta. So, 3 minutes, or less, is fairly good. Anyway, we did an objective study. I had a grant for this, a number of years ago. We actually filmed the time that it took for a learned skilled teacher, whether it was an RT [respiratory therapist], or PharmD, or a MD. Up to a certain point, we would cut it off at 20 minutes. And then, we came back and filmed the patient again, 2 weeks later. With a metered-dose inhaler, which is the one that takes up a lot of time, you have to have 7.5 pounds of hand strength to squeeze off an MDI. So, people with rheumatoid arthritis, and stuff like that can’t do it. Secondly, though, again, depending on your educational level and your age, it really was very frustrating. I didn’t think it was 90%, but despite skilled people teaching for 15 minutes, we had a high error rate at 2 weeks coming back. And, it was documented.
Transcript edited for clarity.