COPD Course : organized by ECI www.copdegypt.org

1. COPD Self-Management

2. Readmissions:
According to Medicare discharge claims, COPD
is listed in the top 3 for readmission within 30
days of discharge.

3. Looking Closer:
Readmission rates 30% in African American
population
Low income accounts for 22% higher
readmission rate
Cost is higher for readmission than for initial
stay
Agency for healthcare, research and quality statistical brief #121, Sept 2011

4. What influences Adherence?
Medication Characteristics
Patient Variables
Clinician Factors

5. What about Adherence:
According to WHO:
"The extent to which a persons behavior taking
medications, following a diet, and or executing
lifestyle changes correspond with agree
recommendations from a health care provider"

6. Types of Non Adherence:
 Erratic non-adherence: Patient understands
and agrees on plan but has difficulty
maintaining regimen
 Unwitting non-adherence: Both patient and
clinician mistakenly believe patient is adherent
 Intelligent non-adherence: Patient deliberately
alters or changes therapy based on reasoned
decision making

7. Poor Adherence According to
WHO:
 >50% of patients have poor adherence in
developed countries
 Impact grows as prevalence grows
 Use patient tailored intervention
 Need to train health care workers to optimize
adherence
 Multidisciplinary approach is needed

8. Non Adherence:
In the United States, non adherence to medical
regimens has been estimated to cost the US
health-care system $100 billion per year. Overall,
therefore, the outcome of non adherence is loss:
loss of opportunities for patients to improve their
health, and loss of medication by health-care
systems, with the subsequent effect of increased
morbidity
Horne, R Concordance and medicines management In the respiratory arena.
2003,Hayward Medical Publications

9. What about the patients?
Survey 1230 peds and 604 adults
▫ 58-79 reported side effects
▫ Most reported to MD
▫ Patient response was to skip treatment (25% ),
adjust dose (33%)
▫ MD more likely to alter adult dose vs peds
White et al, J Allergy Clin Immunol;l, Aug 99

10. Adherence:
 Generally poor
 Peds: Under use 55% of time (electronic
monitor MD I) Coutts et al, Arch Dis Child, Morch,1992
 73% reported use but only 15% actually did and
in same study 14% have >100 actuations 3 hours
before clinic.
Rand at al , Am Rev Respir Dis, june 1992

11. Medication Characteristics:
 Taste
 Schedule
 Side Effects
 Expense
 Delivery Method
 Multiple Doses/Medications
 Prescribed Duration of Medication

12. Common MDI Errors:
Failure to coordinate actuation with Inhalation
(27%)
 Short or no breath-hold after inspiration (26%)
 Too rapid an inspiratory flow rate (19%)
 Inadequate shaking prior to use (13%)
 Stopping inspiration when aerosol hits throat
(6%)
 Firing MDI multiple times during inspiration
 Placing wrong end of inhaler in mouth, holding
upside down, or failure to take cap off

13. Improper Use of Delivery
Devices:
 MDI and Diskus competence very poor in hospitalized
patients
 86% MDI and 71% Diskus misuse
 More likely to misuse if vision impairment or health
literacy is low
 Patients required at least 2 sessions to master technique
 Results suggest that adequate hospital instruction can
overcome these barners to serf-management
 Educate, patient demonstration, critique technique,
reeducate (if necessary)

14. Improper Use of Delivery Devices
(cont):
Results suggest that adequate hospital
instruction can overcome these barners to self-
management
 Educate, patient demonstration.
V.G. Press et al, J Gen Intern Med, Jan 2011

15. Patient Drug Information:
 366 adult patients surveyed upon exiting
pharmacy
 30% of patients indicated that they did not
know the purpose of at least one of their drugs
 69% said they needed more information
 Patients rely on package inserts (36%)
 Patients with limited education required more
information

16. Patient Variable than can Impede
Self-Management
 Misperception of Attack Severity
 Failure to Obtain Medication
 D/C due to Side Effects
 Beliefs and Expectations
 Social Stigma/support
 Income
 Family composition/dynamics
 Memory Loss
 Low Literacy

17. Self-Management Barries.
 Poor health literacy
 Poor audiovisual capabilities
 Inadequate physical capabilities
 Low cognitive capacity

18. Self-Management:
 Self Management education for COPD does
decrease hospital admissions/EO visits
 Inconclusive effect on
▫ Exacerbations
▫ Lung function
▫ Missed days from work
▫ Physician visits

19. Self-Management Study:
Multi-center
 Patients> 50 years
 Stable COPD
 Symptoms under con trol
▫ Randomized:
 Control -usual management
 Study- usual management and enhanced education
Arch Inter Med. Bourbeau J. at al, 2003

20. Self-Management:
 Study group had one hour per week of home
teaching (8 weeks).
 Weekly phone follow-up.
 RT or RN available to patients by phone PRN
Arch Inter Med. Bourbeau J. at al, 2003

21. Self-Management:
 Workbooks
 Action Plans
 Healthy Lifestyle Suggestions
 Home exercise Program
 Traveling with Oxygen
 Inhalation techniques
Arch Inter Med. Bourbeau J. at al, 2003

22. Self-Management:
 COPD
▫ Home visitation by health care professional
resulted in:
 Reduced admissions 40%
 ED visits reduced by 41%
 Unplanned PCP visits by 59%
 Reduction in admjssions for non pulmonary
problems by 57%
Arch Inter Med. Bourbeau J. at al, 2003

23. Action Plans for COPD:
Have been shown to reduce morbidity an
mortality (Bourbeau J, et al. Chest. 2006;130(6):1704-11)

24. What Should be in a COPD Action
Plan?
 Medications (dose, route of delivery, &
..frequency)
 Best FEV1 (if known)
 Best FVC (if known)
 Room air oxygen saturation
 Oxygen setting (frequency and dose)

25. Action Plan:
Symptoms and recommended responses
Contact information (physician, emergency
contact, nearest hospital)
Comorbidities

26. Action Plan:
Some action plans also include general heath
care information such as
▫ Vaccine history
▫ Smoking status (and if still a smoker the plan for
smoking cessation
▫ Exercise plan
▫ Diet plan

27. Conclusion:
Understand the patient's educational need.
Teach to that need and follow up.