Posted on April 15, 2018 in: Professional Practice
By Mike Kwiatkowski, Pharm.D., PGY1 pharmacy resident and Dave Sudekum, Pharm.D., BCPS, pharmacy specialist - internal medicine, St. Joseph Mercy Hospital, Ann Arbor
Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterized by persistent respiratory symptoms and airspace inflammation that leads to inadequate airway patency during expiration.1 Sixteen million Americans are currently diagnosed with COPD, and it is the third leading cause of death in the United States.2 The economic burden of COPD-related patient care was a staggering $32 billion nationally in 2010 with acute exacerbation accounting for over $13 billion of the annual cost.2,3 Upwards of 22 percent of American patients require rehospitalization within 30 days following an acute exacerbation despite estimations that 10 to 55 percent of rehospitalizations after index admission may be preventable.3 Factors associated with early rehospitalization include premature initial discharge, poor discharge medication reconciliation and lack of family education on the disease.3 Pharmacists are positioned throughout the healthcare system to influence and optimize care for patients with COPD.
In May 2017, the National Institute of Health (NIH) published a COPD National Action Plan, calling for a multi-faceted, unified battle against the disease. One of the goals of this plan is to improve the quality of care delivered across the healthcare continuum.2 This can be accomplished through implementation of clinical practice guideline recommendations and disseminating educational information to healthcare providers and patients, amongst other suggestions.2 For inpatient pharmacists, the greatest impact in COPD management can be leveraged through these two aims.
The assessment and implementation of guideline recommendations is paramount in the treatment of COPD for both maintenance inhaler regimens and acute exacerbations. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines stratify patients in groups A-D based upon airflow limitation, symptom burden and exacerbation history.1 Whether a patient is being treated for an acute exacerbation or is admitted with a chief complaint independent of COPD, a pharmacist should ensure the patient is receiving a guideline-recommended inhaler regimen. Expounding upon inhaler selection, consideration of patient-specific factors (i.e., inhaler experience, actuation-breath coordination, fine motor skills, inspiratory flow capacity, and pulmonary function, amongst others) should be evaluated to improve drug delivery and ease of use.4 For patients requiring multiple inhalers, selecting one delivery device (i.e., MDI only) may be beneficial to simplify administration.5 In the event of an exacerbation, pharmacists can assist in determining whether treatment with an antibiotic is appropriate through a review of the three cardinal symptoms: increased dyspnea, sputum volume and sputum purulence.1 For patients satisfying these criteria, treatment for five to seven days with an antibiotic selected based upon local bacterial resistance trends is suggested.1
Providing education and counseling on inhaler administration is crucial for COPD patients as up to 85 percent of patients on chronic COPD treatment use their inhalers ineffectively.5 The pharmacy adage of “drugs don't work in patients who don’t take them”6 can be altered for COPD patients to “drugs don't work in patients who don’t take them properly.” Throughout a hospitalization, inpatient pharmacists have the onus to educate their patients on proper administration technique. Given the time constraint of individually educating all COPD patients admitted at your institution, opportunities to expand your impact include:
For patients with chronic inhaler use, allow them to demonstrate their technique and ability while providing any recommendations for improvement, if necessary. Various educational videos are available to assist in training efforts. Utilizing devices that objectively assess inhalation ability and technique may be the next strategy pharmacists could explore to address proper inhaler usage to ultimately improve patient outcomes.7 Clinical pharmacist-led programs centering around patient self-management and development of an individualized action plan for exacerbations (instructing appropriate management with antibiotics and oral corticosteroids) resulted in a 50 percent decrease in emergency department visits and a 60 percent decline in hospitalizations over a 12-month period.8
Through inhaler administration education, serving as a resource for COPD disease state information to patients and other medical providers, assisting with the management of acute exacerbations and developing programs within your institution, pharmacists can improve patient care and reduce COPD-related rehospitalizations.