Brenda Deering

Objective Assessment of Adherence to Inhalers by COPD Patients.

Rationale: Objective adherence to inhaled therapy by patients with chronic obstructive pulmonary disease (COPD) has not been reported. Objectives: To objectively quantify adherence to preventer Diskus inhaler therapy by patients with COPD with an electronic audio recording device (INCA). Methods: This was a prospective observational study. On discharge from hospital patients were given a salmeterol/fluticasone inhaler with an INCA device attached. Analysis of this audio quantified the frequency and proficiency of inhaler use. Measurements and Main Results: Patients with COPD (n = 244) were recruited. The mean age was 71 years, mean FEV1 was 1.3 L, and 59% had evidence of mild/moderate cognitive impairment. By combining time of use, interval between doses, and critical technique errors, thus incorporating both intentional and unintentional nonadherence, a measure “actual adherence” was calculated. Mean actual adherence was 22.6% of that expected if the doses were taken correctly and on time. Six percent had an actual adherence greater than 80%. Hierarchical clustering found three equally sized well‐separated clusters corresponding to distinct patterns. Cluster 1 (34%) had low inhaler use and high error rates. Cluster 2 (25%) had high inhaler use and high error rates. Cluster 3 (36%) had overall good adherence. Poor lung function and comorbidities were predictive of poor technique, whereas age and cognition with poor lung function distinguished those with poor adherence and frequent errors in technique. Conclusions: These data may inform clinicians in understanding why a prescribed inhaler is not effective and to devise strategies to promote adherence in COPD.

Acupuncture as an adjunct to pulmonary rehabilitation.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation and by both systemic and airway inflammation. In COPD, acupuncture has been shown to improve quality-of-life scores and decrease breathlessness; similar findings have also been reported after pulmonary rehabilitation (PR). The hypothesis of this study was that acupuncture in conjunction with pulmonary rehabilitation would improve COPD outcome measures compared to pulmonary rehabilitation alone. METHODS: The design was a randomized prospective study; all subjects had COPD. There were 19 controls, 25 who underwent PR, and 16 who had both acupuncture and PR. The primary outcome measure was a change in measures of systemic inflammation at the end of PR and at 3 month followup. Lung function, including maximum inspiratory pressure (PiMax), quality-of-life scores, functional capacity including steps taken, dyspnea scores, and exercise capacity, were secondary endpoints. RESULTS: After PR, both groups had significantly improved quality-of-life scores, reduced dyspnea scores, improved exercise capacity, and PiMax, but no change in measures of systemic inflammation compared with the controls. There were no differences in most of the outcome measures between the 2 treatment groups except that subjects who had both acupuncture and PR remained less breathless for a longer period. CONCLUSION: The addition of acupuncture to PR did not add significant benefit in most of the outcomes measured.

COPD care delivery pathways in five European Union countries: mapping and health care professionals’ perceptions

Background COPD is among the leading causes of chronic morbidity and mortality in the European Union with an estimated annual economic burden of €25.1 billion. Various care pathways for COPD exist across Europe leading to different responses to similar problems. Determining these differences and the similarities may improve health and the functioning of health services. Objective The aim of this study was to compare COPD patients’ care pathway in five European Union countries including England, Ireland, the Netherlands, Greece, and Germany and to explore health care professionals’ (HCPs) perceptions about the current pathways. Methods HCPs were interviewed in two stages using a qualitative, semistructured email interview and a face-to-face semistructured interview. Results Lack of communication among different health care providers managing COPD and comorbidities was a common feature of the studied care pathways. General practitioners/family doctors are responsible for liaising between different teams/services, except in Greece where this is done through pulmonologists. Ireland and the UK are the only countries with services for patients at home to shorten unnecessary hospital stay. HCPs emphasized lack of communication, limited resources, and poor patient engagement as issues in the current pathways. Furthermore, no specified role exists for pharmacists and informal carers. Conclusion Service and professional integration between care settings using a unified system targeting COPD and comorbidities is a priority. Better communication between health care providers, establishing a clear role for informal carers, and enhancing patients’ engagement could optimize current care pathways resulting in a better integrated system.

Physical activity patterns and clusters in 1001 patients with COPD

We described physical activity measures and hourly patterns in patients with chronic obstructive pulmonary disease (COPD) after stratification for generic and COPD-specific characteristics and, based on multiple physical activity measures, we identified clusters of patients. In total, 1001 patients with COPD (65% men; age, 67 years; forced expiratory volume in the first second [FEV1], 49% predicted) were studied cross-sectionally. Demographics, anthropometrics, lung function and clinical data were assessed. Daily physical activity measures and hourly patterns were analysed based on data from a multisensor armband. Principal component analysis (PCA) and cluster analysis were applied to physical activity measures to identify clusters. Age, body mass index (BMI), dyspnoea grade and ADO index (including age, dyspnoea and airflow obstruction) were associated with physical activity measures and hourly patterns. Five clusters were identified based on three PCA components, which accounted for 60% of variance of the data. Importantly, couch potatoes (i.e. the most inactive cluster) were characterised by higher BMI, lower FEV1, worse dyspnoea and higher ADO index compared to other clusters (p < 0.05 for all). Daily physical activity measures and hourly patterns are heterogeneous in COPD. Clusters of patients were identified solely based on physical activity data. These findings may be useful to develop interventions aiming to promote physical activity in COPD.

Factors that predict failure in home management of an acute exacerbation of COPD

There is increasing interest in managing patients with non-severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the community. Hospital at Home and COPD Outreach programmes facilitate discharge of patients that would otherwise require hospital admission and have been shown to reduce hospital stay,1 readmission2 and healthcare costs without compromising patient care and satisfaction.3 Despite the human and health-related benefits associated with home services, ∼30% of patients relapse within 8 weeks, requiring hospital readmission.2 In an effort to better understand the factors that predict relapse in these patients, we prospectively studied consecutive admissions with AECOPD discharged to a COPD Outreach programme. Patients with an AECOPD who met specific criteria4 were enrolled within 24 h …

P220 Determinants of inhaler adherence in a copd population

Introduction Inhaler adherence in Chronic Obstructive Pulmonary Disease (COPD) is a crucial component of disease management with studies reporting relationships with both morbidity and mortality. The aim of this study was to identify determinants of inhaler adherence. Methods Over a 3-year period data was collected on 265 patients with COPD whose inhaler adherence was monitored for one month. Data on personal factors (i.e., cognition, anxiety and depression), disease severity and socioeconomic factors was collected. In addition, after one month of recruitment, information on exacerbations, re-admissions, quality of life, symptoms, self-reported adherence, beliefs in medicines and psychological status were collected. Inhaler adherence was calculated as a combination of timing of use, interval between doses and technique of use (Actual Adherence). Results At one month, patients who reported worse breathlessness (5 on the MRC Dyspnoea Scale) had worse Actual Adherence (p = 0.03). Interestingly, patients who had an exacerbation of their COPD within the month after recruitment had significantly lower Actual Adherence than those that didn’t (p = 0.01). In addition, patients with poorer cognition (p = 0.02), poorer cough PEFR (p < 0.01) and more severe COPD (GOLD Stage IV, p = 0.05) had worse Actual Adherence. Conclusion In the large observational study of severe COPD patients, poor inhaler adherence was associated with worse symptoms, poorer cognition, more severe COPD and more exacerbations. This has significant implications for the long-term treatment of this patient population and may guide future interventions.