Breaking Down Barriers to Pulmonary Therapies: Patient ... · 6/11/2015 2 GOLD for COPD COLD COPD’s Impact Fourth leading cause of death in the world Leading cause of morbidity

6/11/2015

1

Breaking Down Barriers to Pulmonary Therapies:

Patient Education, Teach Back, and More

Char Raley, RRT

Brandon Johnson, PharmD, BCPS

Pulmonary and Critical Care Symposium June 12th, 2015

We have had no financial relationships over the past 12 months with any commercial sponsors with a vested interest in this presentation.

Objectives

Review recommended therapies for Chronic Obstructive Pulmonary Disease (COPD)

Describe Teach-Back and how to utilize in respiratory therapy

Identify barriers to pulmonary therapies and describe how to mitigate them

6/11/2015

2

GOLD for

COPD

COLD

COPD’s Impact Fourth leading cause of death in the world

Leading cause of morbidity and mortality in the world with significant economic and social burden

Prevalence and burden are projected to increase

Associated with many comorbidities

World Health Report. Geneva: World Health Organization.; 2000.

Lopez AD, et al. Eur Respir J 2006;27:397-412.

Mathers CD, et al. PLoS Med. 2006;3:e442.

Barnes PJ, et al. Eur Respir J 2009;33:1165-85.

6/11/2015

3

Classification of Airway Limitation In patients with FEV1/FVC < 0.70

COPD Stage FEV1 * Exacerbations/yr Hospitalizations/yr 3-yr mortality

GOLD 1, Mild

≥ 80% Unknown Unknown Unknown

GOLD 2, Moderate

50-79% 0.7-0.9 0.11-0.2 11%

GOLD 3, Severe

30-50% 1.1-1.3 0.25-0.3 15%

GOLD 4, Very Severe

< 30% 1.2-2.0 0.4-0.54 24%

*Post bronchodilator measurement Global Initiative for Chronic Obstructive Lung Disease.

Accessed 2 Apr 2015.

COPD Medications Maintenance: As needed or “Rescue”:

Long-acting beta2-agonists

LABA

Long-acting anticholinergic

Inhaled Corticosteroids

ICS

Combo: LABA+ICS

Methylxanthines (theophylline

Systemic Steroids

PDE4-inhibitor (roflumilast)

Short-acting beta2-agonists

SABA

Short-acting anticholinergic

Combo: SABA + SA-Anticholinergic

6/11/2015

4

SABA or

LA-antichol.

+LA antichol.

Or LABA

+LA antichol.

+ LABA+ICS

+LA antichol.

± LABA+ICS

Adjunct Therapies: Theophylline PDE4-inhibitor Steroids

Non-pharmacologic Interventions COPD Assessment Essential Recommended

Group A Smoking Cessation ±pharmacologic assistance

Physical Activity

Yearly Influenza Vaccine

Pneumococcal Vaccine Groub B - D Smoking Cessation ±pharmacologic assistance

Pulmonary Rehab

Very Severe COPD therapy options: Oxygen therapy (>15 hours/day) Surgical Interventions

6/11/2015

5

Teach Back

Teach back is so important because it gives you an

opportunity to see if your patient is understanding

the education session.

“The main problem with communication is the

assumption that it has occurred.”

-George Bernard Shaw

6/11/2015

6

Health Literacy Strategies Are you speaking clearly and listening carefully?

Is the information appropriate for the user?

Is the information easy to use?

Use a medically trained interpreter for language barriers

Adapt for learning ability

Check for understanding frequently

6/11/2015

7

Use of Valved Holding Chambers

Unless you’ve got the reflexes of a NASCAR driver or compulsive video gamer, catching that fleeting premeasured dose in a slow, deep inhalation is almost impossible.

ALLERGY & ASTHMA TODAY FAL L 2007

Spacer Technique (~3.5 years old)

In-check Dial

The DIAL can be adjusted to accurately simulate the resistance of popular inhaler

devices which include MDI’s and DPI’s such as Turbuhaler®, Flexhaler®,

Twisthaler®, Aerolizer®, Handihaler® and Diskus® among others. The In Check

DIAL enables clinicians to train patients to the proper inspiratory technique

considering force and flow rate to achieve optimal deposition of the medication

being inhaled into the lungs. 2015 Alliance Tech Medical, Inc

6/11/2015

8

RRT Barrier #1- Smoking Cessation

The patient will not quit smoking until they are ready.

Refer to your state quit line.

Helpful hints.

6/11/2015

9

RRT Barrier #2- Medication Cost

Coupons/Programs

Financial Advocates

RRT Barrier #3

Med WRECK-onciliation

Ask all the questions

When, how many, show me!

RRT Barrier #4- Meds prescribed at home are not consistent with GOLD Standards

Make recommendations to the discharging docs.

Fax the PCP after discharge if needed.

6/11/2015

10

Pharmacist’s role in care of inpatients

Review patient cases and pharmacotherapy orders for inpatient and orders upon discharge

Patient education based upon priority/complexity, discharge disposition, pharmacist and/or patient availability

Rx Barrier 1 Patient does not have pulmonary meds despite being

diagnosed with COPD

Possible med-reconciliation omission

Medication cost issue

6/11/2015

11

Rx Barrier 2

Provider forgot to order Nebulizer-machine for new Neb-medications

Rx Barrier 3 Patients do not take pulmonary therapies as prescribed

Maintenance meds are stopped when symptoms subside

Complex medication regimen

Multiple comorbidities

Simplify when appropriate

Leuppi JD, et al. JAMA. 2013;309(21):2223-2231

Medication cost

Rx Barrier 4 Patient has Rx insurance related issues

Preferred therapies vs less preferred therapies

Medicare Part B (Nebs) vs. Part D (Inhalers)

“24-hour Neb rule” by Medicare

6/11/2015

12

Success Stories

Coordinating education and care from the time of admission with the entire medical team.

Monthly multidisciplinary meetings

Pharmacy

Financial Advocates

RT Education

Care Transitions and Home Care

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of COPD. http://www.goldcopd.org/uploads/users/files/GOLD_Report2014_Feb07.pdf. Accessed 2 Apr 2015.

World Health Report. Geneva: World Health Organization. Available from URL: http://www.who.int/whr/2000/en/ statistics.htm; 2000.

Lopez AD, Shibuya K, Rao C, et al. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J 2006;27:397-412.

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3:e442.

Barnes PJ, Celli BR. Systemic manifestations and comorbidities of COPD. Eur Respir J 2009;33:1165-85.

Leuppi J, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease. JAMA. 2013;309(21):2223-2231.

Questions? Char Raley, RRT

Avera McKennan Respiratory Therapy Coordinator of Pulmonary Education

[email protected] | 605.322.8612

Brandon R. Johnson, Pharm D, BCPS

Clinical Pharmacist – Internal Medicine

[email protected]